Biomarkers related to organ function

ABSTRACT

Disclosed herein are methods of identifying biomarkers (such as genes (e.g., RNA or mRNA), proteins, and/or small molecules) that can be used to predict organ or tissue function or dysfunction. In some embodiments, the methods include ex vivo perfusion of the organ or tissue, collection of samples from the organ or tissue (for example, perfusate, fluids produced by the organ (such as bile or urine), or tissue biopsies) and measuring the level of one or more biomarkers in the sample. It is also disclosed herein that an analysis of biomarkers (such as genes (e.g., RNA or mRNA), proteins, and/or small molecules) present in a biological sample from an organ, tissue, or subject can be used to identify whether the organ, tissue, or subject is at risk for (or has) organ dysfunction or organ failure.

CROSS REFERENCE TO RELATED APPLICATION

This is a continuation of U.S. application Ser. No. 15/024,297, filed Mar. 23, 2016, which is the § 371 U.S. National Stage of International Application No. PCT/US2014/057049, filed Sep. 23, 2014, which was published in English under PCT Article 21(2), which in turn claims the benefit of U.S. Provisional Application No. 61/881,333, filed Sep. 23, 2013, which is incorporated by reference herein it its entirety.

FIELD

This disclosure relates to biomarkers related to organ or tissue function, particularly methods of identifying such biomarkers utilizing an ex vivo perfusion system and methods of predicting organ or tissue function by determining one or more biomarkers.

BACKGROUND

There are a large and increasing number of individuals in need of organ transplantation. Transplant candidates' waiting times have continued to grow around the world, imposing further morbidity and mortality for this population. Meanwhile, the discard rates of human organs have continued to increase in spite of the high mortality rate on the transplant waiting lists (18 patients/day) across the country.

Even when an appropriate transplant organ is obtained, failure rates of transplanted organs range from 5-25%. Furthermore, organ dysfunction (such as liver or kidney dysfunction) is becoming increasingly common in the general population. Thus, there is a need to identify biomarkers for organ dysfunction, for both organs for transplantation and in individuals who have or are at risk for organ dysfunction.

SUMMARY

Disclosed herein are methods of identifying biomarkers (such as nucleic acids (e.g., DNA, RNA or mRNA), proteins, and/or small molecules) that can be used to predict organ or tissue function or dysfunction. In some embodiments, the methods include ex vivo perfusion of the organ or tissue, collection of samples from the organ or tissue (for example, perfusate, fluids produced by the organ (such as bile or urine) or tissue biopsies) and measuring the level of one or more biomarkers in the sample. In some embodiments, the organ is perfused with a hemoglobin-based oxygen carrier (HBOC) solution. The organ function (or dysfunction) is analyzed and biomarkers associated with organ function or dysfunction are identified. In some examples, one or more biomarkers that increase or decrease in organs with good function (for example compared with a reference or control) are identified as predictors of organ function. In other examples, one or more biomarkers that increase or decrease in organs with poor function (for example, compared with a reference or control) are identified as predictors of organ dysfunction.

It is also disclosed herein that an analysis of biomarkers (such as nucleic acids (e.g., DNA, RNA or mRNA), proteins, and/or small molecules) present in a biological sample from an organ, tissue, or subject can be used to identify whether the organ, tissue, or subject is at risk for (or has) organ dysfunction or organ failure. In some embodiments, the methods utilize analyzing gene expression profiles, protein profiles, and/or small molecule profiles of metabolites. In other embodiments, the methods utilize analyzing the presence of one or more specific genes, proteins, and/or metabolites. These methods can be used, for example, to identify individuals at risk of (or having) organ dysfunction or failure or identify organs that are suitable or unsuitable for organ transplantation. In particular disclosed examples, the methods determine biomarkers associated with liver dysfunction (such as liver failure) and can be used to assist in the identification of persons with liver disease, to assess the severity of liver disease and the necessity of liver transplantation, and to help identify or rank donated livers in terms of their suitability for transplantation and/or likelihood of long-term organ survival following transplantation.

The foregoing and other features of the disclosure will become more apparent from the following detailed description, which proceeds with reference to the accompanying figures.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic diagram showing an exemplary methodology for biomarker analysis in an ex vivo perfusion model.

FIGS. 2A-2G are a series of graphs showing post-operative levels of lactate (FIG. 2A), albumin (FIG. 2B), AST (FIG. 2C), ALT (FIG. 2D), BUN (FIG. 2E), creatinine (FIG. 2F), and peripheral blood pH (FIG. 2G) in the control and study group animals.

FIG. 3 is a graph showing histological analysis of ischemia-reperfusion (IR). IR scores (Suzuki modified) were determined by serial analysis of inflammatory changes within the portal tracts and the hepatic lobules. The graphic shows a longitudinal comparison of average IR scores for cold static preservation (CSP—(b)) and machine perfusion (MP—(a)). The IR scores at necropsy were significantly lower in the MP group (p=0.01), showing the benefits of effective ex-vivo oxygenation on liver tissue viability after transplantation.

FIGS. 4A-4C are a series of graphs showing mitochondrial function in control and study groups. FIG. 4A shows respiratory control ratio, FIG. 4B shows ATP production, and FIG. 4C shows reactive oxygen species generation (H₂O₂).

FIG. 5 is a graphic representation of the transcriptomic analysis (microarray) of 20,000 genes obtained from pig liver samples after machine perfusion showing the top 100 genes with increased expression after 8 hours sustained ex vivo oxygenation before liver allograft implantation.

FIG. 6 is a graphic representation of the transcriptomic analysis (microarray) of 20,000 genes obtained from pig liver samples showing the genes with the greatest differences in gene expression immediately following liver allograft reperfusion compared to the fifth post-operative day (end-study necropsy).

FIG. 7 shows pathway analysis (Ingenuity®) of genes with altered expression in the machine perfusion group (top) or cold ischemia group (bottom) at the fifth post-operative day (end-study necropsy) from microarray analysis of 20,000 genes. The machine perfusion group showed that genes associated with liver damage were significantly down-regulated, while the cold ischemia group showed significant up-regulation of genes associated with liver pathology.

FIG. 8 is a graphic representation of the transcriptomic analysis (microarray) of 20,000 genes obtained from pig liver samples showing the enrichment by biological process networks following 8 hours of machine perfusion (Ingenuity®).

FIG. 9A is a graphic representation of the transcriptomic analysis (microarray) of 20,000 genes obtained from pig liver samples showing the metabolic network analysis (Ingenuity®) following 8 hours of machine perfusion. Effective ex-vivo oxygenation enhanced significantly (p=0.01) the genes regulating drug, amino acid, free radical scavenging, vitamin, mineral and carbohydrate metabolism while enhancing energy production.

FIG. 9B is a graphic representation of the transcriptomic analysis (microarray) of 20,000 genes obtained from pig liver samples showing the metabolic network analysis (Ingenuity®) following 8 hours of machine perfusion. Effective ex-vivo oxygenation enhanced significantly (p=0.01) the genes regulating biological processes involved in hepatic system development and function, cellular growth and proliferation, cellular morphology, cellular development, cellular signaling, cellular assembly and organization, cell-to-cell signaling and interaction, tissue morphology and cellular function and maintenance. Increased expression of several genes associated with entry of hepatocytes into G1 phase was observed.

FIG. 10 is a graphic representation of the transcriptomic analysis (microarray) of 20,000 genes obtained from pig liver samples showing the metabolic network analysis (Ingenuity®) following 8 hours of machine perfusion. Effective ex-vivo oxygenation enhanced significantly (p=0.01) the genes expression of signaling pathways that are critical for liver growth. NF-κB can inhibit the TNF-α induced apoptotic pathway and increase the expression of survival gene products.

FIG. 11 is a graph showing interferon-α levels in control (cold ischemia) and experimental (machine perfusion) samples. Overall two-way ANOVA p=0.001.

FIG. 12 is a graph showing tumor necrosis factor-α levels in control (cold ischemia) and experimental (machine perfusion) samples. Overall two-way ANOVA p=0.032.

FIG. 13 is a graph showing interferon-γ levels in control (cold ischemia) and experimental (machine perfusion) samples. Overall two-way ANOVA p=0.022.

FIG. 14 is a graph showing interleukin-4 levels in control (cold ischemia) and experimental (machine perfusion) samples. Overall two-way ANOVA p=0.021.

FIG. 15 is a graph showing interleukin-10 levels in control (cold ischemia) and experimental (machine perfusion) samples. Overall two-way ANOVA p=0.001.

FIG. 16 is a graph showing interleukin-12/interleukin-23 (p40) levels in control (cold ischemia) and experimental (machine perfusion) samples. Overall two-way ANOVA p=0.001.

FIGS. 17A-17C are a series of graphs showing branched chain amino acids in machine perfused livers and cold ischemia livers over the course of the experiment (hours). FIG. 17A shows valine, FIG. 17B shows leucine, and FIG. 17C shows isoleucine. The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIGS. 18A-18B are a series of graphs showing Krebs pathway byproducts in machine perfused livers and cold ischemia livers over the course of the experiment (hours). FIG. 18A shows alpha-ketoglutarate, FIG. 18B shows citrate. The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIGS. 19A-19W are a series of panels of graphs showing different metabolites in machine perfused livers and cold ischemia livers over the course of the experiment (hours). The upper line in each plot is the machine perfused liver, except for 3-hydroxypropanoate, beta-alanine, butylcarnitine, C-glycosyltryptophan, creatinine, eiconsenoate (20:1n9 or 11), ethanolamine, galactose, GABA, gluconate, glutathione, oxidized (GSSG), glycerol 2-phosphate, glycerol 3-phosphate (G3P), glycerophosphorylcholine, glycohenodeoxycholate, glycocholate, glycohyodeoxycholic acid, glycolithocholate, guanosine, hippurate, hypotaurine, hypoxanthine, inosine, ketamine, ophthalmate, ribose 1-phosphate, ribose 5-phosphate, S-methylglutathione, spermine, sucrose, succinate, taurine, taurocholate, uridine, and verbascose, where the lower line is the machine perfused liver. The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIGS. 20A-20E are a series of graphs showing compounds of the gluconeogenesis pathway in machine perfused livers and cold storage livers over the course of the experiment (hours). FIG. 20A shows glucose, FIG. 20B shows lactate, FIG. 20C shows pyruvate, FIG. 20D shows fructose 6-phosphate, and FIG. 20E shows glucose 6-phosphate. The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIGS. 21A and 21B are a pair of graphs showing alpha-ketoglutarate (FIG. 21A) and glutamate production (FIG. 21B) in machine perfused and cold storage liver perfusate over the course of the experiment (hours). The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIG. 22 is a graph showing ascorbate in in machine perfused and cold storage liver perfusate over the course of the experiment (hours). The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIGS. 23A and 23B are a pair of graphs showing 15-HETE (FIG. 23A) and 12-HETE (FIG. 23B) in machine perfused and cold storage liver perfusate over the course of the experiment (hours). The X-axis shows concentration in I/U. The Y-axis shows 3 time points (0=3 hours, 5=6 hours and 10=9 hours) when samples were obtained.

FIG. 24 is a graph showing bile production in the post-operative period by machine perfused (study) and cold storage (control) animals following allograft reperfusion.

FIG. 25 is a graph showing principal component analysis (PCA) carried out on the metabolomic profile of perfusate at three time points (3, 6 and 9 hours). Variables are ordered by the sum of their contribution to all components, with contributions to individual components represented by different colored sections of the bars. In MP livers, variables representing carbohydrate metabolism (ribulose, ribose, glycolate) and antioxidant defenses (oxidized homo-glutathione—GSSG) were principal drivers of metabolic changes.

FIG. 26 is a graph showing PCA carried out on the metabolomic profile of perfusate at three time points (3, 6 and 9 hours). Variables are ordered by the sum of their contribution to all components, with contributions to individual components represented by different colored sections of the bars. In CSP livers, PCA showed ethanolamine to be the principal driver of metabolic changes, suggesting a role for fatty acid metabolism.

FIG. 27 is a representation of the method Dynamic Bayesian Networks (DBN) utilized to establish the role of different cytokines while interacting in response to an initial inflammatory event (e.g. ischemia-reperfusion acquired during liver preservation).

FIG. 28 shows DBN analysis suggesting two different pathways for cytokine regulation in livers being perfused by different techniques (Control with cold static preservation—CSP and Study with machine perfusion in combination with the hemoglobin-based-oxygen carrier solution—MP/HBOC).

DETAILED DESCRIPTION

Disclosed herein is a new discovery platform for biomarkers related to organ or tissue function, particularly methods of identifying such biomarkers utilizing an ex vivo perfusion system where organs can be perfused outside of the body for several hours by a system combining machine perfusion with a cell free oxygen carrier solution at variable temperatures. This system providing effective oxygenation through ex vivo perfusion for several hours can be utilized to assess tissue and organ viability (for both acute and long term features) while determining the role of biochemical components (e.g., transcriptomics, cytokines, chemokines, damage-associated molecular pattern molecules (DAMPs), toll-like receptors (TLRs) and/or metabolomics) in predicting subsequent organ function.

This system can also map out biological features related to a previously known disease (diabetes, hypertension, steatosis, acute kidney injury, etc.) experienced by a subject, whose organs can be further studied post-mortem by this new ex vivo perfusion environment. This should create a new platform to define cardinal events for acute (e.g., initial markers involved in acute organ failure) and chronic diseases (e.g., initial cell signaling for the development of fibrosis) that are currently limited by the subject's survival. Finally, this technology represents a new model system, for testing new therapies and diagnostics for acute diseases of solid organs.

The current platforms utilized for the discovery of clinically-relevant biomarkers related to organ function and additional medical conditions are primarily based on biological samples (e.g., blood, urine, bile, saliva, etc.) obtained from live individuals. Biomarkers can be divided in pharmacodiagnostic, pharmacological, and disease related categories. These biochemicals are essential tools in preventive and personalized medicine, modern drug development, and in outcomes prediction for medical treatment and/or diseases.

Predictive biomarkers are the building blocks for personalized medicine when capable to enhance the evidence-based environment needed for subsequent diagnostic and therapeutic decisions. These new biomarkers should reflect the heterogeneity of human diseases while stratifying patients and biological pathways within their predictable outcomes. The early discovery and exploratory phases involving the inception of new biomarkers are rather lengthy and expensive, since the initial data collection relies primarily on live patients and their body fluids in a rather diverse geographic and clinical environment.

This disclosure describes a new platform for the development of biomarkers that is primarily centered on organs and tissues being perfused by machine perfusion technology in association with a recently developed cell-free oxygen carrier solution (discussed below). This ex vivo discovery platform for biomarkers can also be used to predict organ function prior to organ transplantation. Finally, developing new therapies for acute diseases has been challenging because existing model systems involving animals (even transgenic animals) and cell cultures often do not yield results that translate into humans. The platform disclosed herein offers a unique solution to this problem by using human organs and subjecting them to a variety of acute pathologies including infection, trauma and ischemia in order to study treatments and diagnostics.

In some embodiments, biomarkers can be identified for pharmacodiagnostic applications (e.g., treatment eligibility, treatment response prediction, drug safety, and/or assessing the efficacy of a given therapy), pharmacological applications (e.g., pharmacodynamics markers, pharmacokinetic markers, and/or outliners of intrinsic mechanisms of action), disease and medical conditions (e.g., screening for a given condition, early prognostic feature, early detection, monitoring tool to detect clinical evolution and recurrence of a given disease), and/or organ transplantation (e.g., predictive marker for organ function, predictive marker for ischemia-reperfusion injuries, predictive factor for immune compatibility, predictive of vascular integrity, and/or predictive of subsequent fibrosis development within the allograft).

I. Terms

In order to facilitate review of the various embodiments of this disclosure, the following explanations of specific terms are provided:

Biomarker: An organic biomolecule, such as a small molecule, amino acid, sugar, carbon (energy) source, carbohydrate, nucleic acid (such as DNA, RNA, or mRNA, referred to in some examples herein as “genes”) or a polypeptide or protein, which is differentially present in a biological sample. In one example, the biomarker is present in a sample taken from an organ or tissue or a subject who is, or may be at risk for, or has, organ dysfunction. A biomarker can be differentially present in samples from a normal (e.g., healthy or functional) organ, tissue, or subject and samples from an organ, tissue, or subject having or at-risk for organ dysfunction, if it is present at an elevated level or a decreased level in the latter samples as compared to normal samples.

Hemoglobin-based oxygen carrier (HBOC): Molecules or compositions with oxygen carrying capabilities derived from the presence of hemoglobin. In some examples, HBOCs include isolated or purified hemoglobin (sometimes referred to as “acellular” HBOCs). Exemplary acellular HBOCs contain polymerized hemoglobin (for example, bovine or human hemoglobin), for example HBOC-201 (HEMOPURE, OPK Biotech, Cambridge, Mass.), HEMOLINK (Hemosol, Inc., Toronto, Canada), and POLYHEME (Northfield Laboratories, Evanston, Ill.) or encapsulated hemoglobin (such as liposome- or polymersome-encapsulated hemoglobin). In other examples, HBOCs include red blood cells.

Metabolome: All of the small molecules present in a given sample, tissue, organ, or subject. The metabolome includes both metabolites as well as products of catabolism. In one embodiment, the disclosure encompasses a small molecule profile of the entire (or substantially entire) metabolome of a sample. In other embodiments, the disclosure encompasses a profile of one or more molecules of the metabolome of a sample. Generally the metabolome or small molecule profile includes those molecules with a molecular weight of less than 2,000 Daltons Small molecules do not include large macromolecules, such as proteins (for example, proteins with molecular weights over 2,000, 3,000, 4,000, 5,000, 6,000, 7,000, 8,000, 9,000, or 10,000 Daltons), large nucleic acids (such as nucleic acids with molecular weights of over 2,000, 3,000, 4,000, 5,000, 6,000, 7,000, 8,000, 9,000, or 10,000 Daltons), or large polysaccharides (such as polysaccharides with a molecular weights of over 2,000, 3,000, 4,000, 5,000, 6,000, 7,000, 8,000, 9,000, or 10,000 Daltons). The molecules shown in FIG. 1-A-19W and Tables 8 and 9 are non-limiting examples of small molecules of the metabolome.

Organ: A part of the body, tissue, or portion thereof. In some examples, organs include those that can be transplanted or preserved ex vivo. Organs include, but are not limited to liver, kidney, heart, lung, pancreas, small intestine, and limb (such as arm or leg, or portion thereof), or extremity (such as hand, foot, finger, toe, or a portion thereof). As used herein, “organ” also includes other tissues, such as tissue grafts, such as composite tissue allografts.

Organ dysfunction: Organ dysfunction is a biological and dynamic condition where an organ does not perform its expected function (e.g., has impaired function). Organ dysfunction can migrate towards organ failure if remained untreated. Organ dysfunction can lead into the deregulation of the body homeostasis when metabolically active and filtering organs like liver and kidneys are affected. One example of kidney dysfunction is in drug toxicity leading into renal failure (e.g., excessive use of NSAIDS). In some examples, kidney dysfunction includes decreased glomerular filtration rate due to progressive vasospasm of afferent arterioles within the nephron. An example of liver dysfunction is in metabolic syndrome following morbid obesity. In some examples, liver dysfunction includes enhanced metabolic pathways to gluconeogenesis, followed by fat deposition within hepatocyte cytoplasm, leading to hepatic steatosis.

Perfusion: Circulation of a fluid (also referred to as a perfusion solution or perfusate) through an organ to supply the needs of the organ to retain its viability (for example, in an ex vivo system). In some examples, the perfusion solution includes an oxygen carrier (for example, a hemoglobin-based oxygen carrier). Machine perfusion refers to introduction and removal of a perfusion solution to an organ by a mechanical device. Such devices may include one or more chambers for holding an organ and a perfusion solution, one or more pumps for delivery of the perfusion solution to the organ, one or more means to regulate temperature of the perfusion solution, and one or more means to oxygenate the perfusion solution. In some examples, machine perfusion includes introduction of an oxygen carrying fluid into an organ and removal of oxygen depleted fluid from the organ by circulation of the oxygen carrying fluid through the organ.

Sample: A specimen containing genomic DNA, RNA (including mRNA), protein, small molecules or combinations thereof, obtained from an organ, tissue, or subject. In some examples, a sample is from an ex vivo tissue or organ, such as perfusate from an ex vivo perfused tissue or organ, fluids produced by an organ or tissue (such as bile, urine, or tissue exudate), or a biopsy from an organ or tissue. Additional examples include, but are not limited to, peripheral blood, bile, urine, saliva, tissue biopsy, fine needle aspirate, surgical specimen, and autopsy material from a subject.

Subject: Living multi-cellular vertebrate organisms, a category that includes human and non-human mammals, such as veterinary subjects.

II. Methods of Identifying Biomarkers of Organ or Tissue Function

Disclosed herein are methods of identifying biomarkers (such as genes (e.g., RNA or mRNA), proteins, and/or small molecules) that can be used to predict organ or tissue function or dysfunction. An advantage of the methods disclosed herein is that samples are obtained from ex vivo tissues or organs, which do not have interference from blood products or cells and does not implicate further allosensitization of the tissue or organ under perfusion. An additional advantage of the methods disclosed herein is that organs that are not suitable for transplantation and would otherwise be discarded can be utilized to identify biomarkers of organ dysfunction. In particular embodiments described herein, the organ is a liver; however, any perfusable organ or tissue (such as liver, kidney, lung, heart, pancreas, small intestine, limbs (for example, arm or leg), extremities (for example, hand, foot, finger, toe, or face)), or a portion thereof can be utilized in the disclosed methods.

In some embodiments, the methods include ex vivo perfusion of the organ or tissue, collection of samples from the organ or tissue (for example, perfusate, fluids produced by the organ (such as bile or urine), or tissue biopsies) and measuring the level of one or more biomarkers in the sample. In some embodiments, the organ is perfused with a hemoglobin-based oxygen carrier (HBOC) solution. The organ function (or dysfunction) is analyzed and biomarkers associated with organ function or dysfunction are identified. In some examples, one or more biomarkers that increase or decrease in organs with good function (for example compared with a reference or control) are identified as predictors of organ function. In other examples, one or more biomarkers that increase or decrease in organs with poor function (for example, compared with a reference or control) are identified as predictors of organ dysfunction.

In particular embodiments, the methods include determining presence and/or amount of one or more biomarkers, such as one or more biomarkers from a genome, transcriptome, proteome, and/or metabolome of a tissue, organ, or subject, for example as shown schematically in FIG. 1. The function (or dysfunction) of the tissue or organ or the health status of the subject from which the sample was obtained is determined or monitored. Biomarkers that increase or decrease in a tissue, organ, or subject with good function, health, or a positive outcome are identified as predictors of organ or tissue function. Biomarkers that increase or decrease in a tissue organ, or subject with poor or decreased function, health, or a poor outcome are identified as predictors of organ or tissue dysfunction.

In particular examples, the methods include obtaining samples from an ex vivo perfused organ or tissue. The samples include one or more of perfusate, fluid produced by the organ or tissue (such as bile, urine, or tissue exudate), or tissue biopsy samples. The organ or tissue can be machine perfused by any method known to one of ordinary skill in the art. In some examples, the machine perfusion is carried out with a perfusion solution that includes an oxygen carrier, such as a hemoglobin-based oxygen carrier (HBOC). In one particular example, the machine perfusion is carried out with a perfusion solution that includes a modified HBOC solution comprising a 1:3 mixture of HEMOPURE (OPK Biotech, Cambridge, Mass.) and Belzer machine perfusion solution (BMPS) (e.g., Muhlbacher et al., Transplant. Proc. 31:2069, 1999; Kwiatkowski et al., Transplant. Proc. 33:913, 2001; Stubenitsky et al., Transplant. Int. 68:1469, 1999). The modified HBOC solution is described in detail in U.S. Prov. Pat. Appl. No. 61/713,284, filed Oct. 12, 2012, and International Pat. Publ. No. WO 2014/059316, both of which are incorporated herein by reference in their entirety. However, other machine perfusion solutions known to one of ordinary skill in the art can also be utilized.

In some examples, the methods can also include obtaining samples from an ex vivo organ or tissue that is not machine perfused, for example a tissue or organ that is treated by cold storage in a preservation solution. In one example, the cold storage preservation (CSP) solution is UW solution, which is the current standard of care for preservation of organs for transplantation. Organs preserved by CSP in UW solution frequently have poor function (dysfunction), as described in Example 1, below. In some examples, samples from CSP organs are controls for comparison with samples from machine perfused organs, which generally have better function and outcome (see Example 1, below).

The samples obtained from the tissue or organ are analyzed for presence and/or amount of one or more biomarkers. In some examples, the genome or transcriptome is analyzed to determine gene expression biomarkers, for example, samples are analyzed for presence and/or amount of one or more nucleic acids (such as DNA, RNA, mRNA, or miRNA). In particular examples, the nucleic acids analyzed are related to cell proliferation or cell differentiation.

In other examples, the samples are analyzed for presence and/or amount of one or more proteins or polypeptides, such as analysis of the proteome of the sample. In particular examples, the cytokine and/or chemokine profile of the sample is analyzed (for example, one or more of interferon-α, interferon-γ, interleukin-10, interleukin-12/23 (p40), interleukin-1b, interleukin-4, interleukin-6, interleukin-8, and/or tumor necrosis factor-α); however, any protein of interest can be analyzed. In additional examples, the proteins analyzed include hormones, clotting factors, paracrine factors, and/or growth factors. Exocrine secretions may also be analyzed, for example, exocrine secretions produced by the pancreas or the intestines. In one non-limiting example, hepatocyte growth factor is analyzed. In other examples, one or more of VEGF, TGF-β, ERK/MAPK, ErbB, FAK, HGF, p53, insulin receptor, PI3K/AKT, PDGF, FGF, EGF, and NF-κB are analyzed.

In particular examples, nucleic acid or protein biomarkers are analyzed in a tissue sample (such as a biopsy) from an organ, tissue, or subject. However, in some instances, nucleic acids or proteins can also be analyzed in perfusate from a machine perfused organ or tissue or in a fluid from an organ (such as bile or urine).

In further examples, the samples are analyzed for presence and/or amount of one or more small molecules, for example, analysis of the metabolome of the sample. In particular non-limiting examples, the small molecule profile is analyzed in perfusate from an ex vivo perfused organ, bile, or urine.

Methods of detecting presence and/or amount of nucleic acids, proteins, and small molecules are described in Section IV, below.

In some examples, the amount of the one or more biomarkers is compared with the amount of one or more biomarkers in a control or reference sample. In some examples, a “control” refers to a sample or standard used for comparison with an experimental sample, such as a sample or standard from one or more organs with known function or dysfunction. In some embodiments, the control is a sample obtained from a healthy organ. In some embodiments, the control is a historical control or standard reference value or range of values (such as a previously tested control sample, such as a group of samples that represent baseline or normal values, such as the level of one or more biomarkers in a healthy organ). In other embodiments, the control is a sample obtained from a dysfunctional organ. In some embodiments, the control is a historical control or standard reference value or range of values (such as a previously tested control sample, such as a group of samples that represent the level of one or more biomarkers in an organ with dysfunction).

One of skill in the art can identify healthy and/or dysfunctional organs. In some examples, organs (such as human organs) can be thoroughly examined for one or more metabolic features while under ex vivo machine perfusion in order to determine parameters of healthy or dysfunctional organs. The energy production pathways (e.g., glycolytic or glyconeogenic pathways) can by elucidated while outlining additional biological features on carbohydrate, lipid, amino acids, vitamin and minerals metabolism, as well as their free radical scavenging abilities. In one particular example, levels of lactate dehydrogenase, glutathione-S-transferase and aspartate transaminase are correlated with delay graft function of cadaveric kidney allografts (Bhangoo et al., Nephrol Dial Transplant 27:3305, 2012).

One of skill in the art can readily identify statistical methods and computer programs that can be used to identify an increase or a decrease (such as a statistically significant increase or decrease) in one or more biomarkers, including differences in molecule profiles. Methods of analysis that can be used include linear discriminant analysis and Random Forest analysis. Additional methods of analysis include Principal Component Analysis (PCA) and Dynamic Bayesian Networks (DBN). In some examples, these methods can be used to identify a principal component itself or variations as an increase or a decrease (such as a statistically significant increase or decrease) in one or more biomarkers. One of ordinary skill in the art can identify additional suitable methods of analysis to identify increases or decreases in biomarkers.

III. Methods of Predicting Organ Function or Dysfunction

Disclosed herein are methods for predicting organ function or dysfunction and methods of treating an organ or subject with predicted dysfunction. The methods include an analysis of biomarkers (such as genes (e.g., RNA or mRNA), proteins, and/or small molecules) present in a biological sample from an organ, tissue, or subject to identify whether the organ, tissue, or subject is at risk for (or has) organ dysfunction or organ failure. In some embodiments, the methods utilize analyzing gene expression profiles, protein profiles, and/or small molecule profiles of metabolites. In some examples a gene expression profile, protein profile, or small molecule profile includes 5 or more (such as 10, 15, 20, 25, 50, 100, 200, 500, 1000, or more) genes, proteins, or small molecule metabolites, respectively. In other embodiments, the methods utilize analyzing the presence of one or more (such as 2, 3, 4, 5, 10, 15, 20, 25, 30, 40, 50, 60, 70, 80, 90, 100, or more) specific genes, proteins, and/or metabolites. In particular embodiments, the profiles or particular biomarkers include one or more of the genes, proteins, and/or small molecules listed in any one of FIGS. 5-7, 10-23, 25, 26, and 28 and Tables 8 and 9, or any combination thereof. Exemplary methods of analyzing biomarkers from a sample are discussed in Section IV, below.

In some embodiments, the methods include determining the level of one or more (such as 2, 3, 4, 5, 5, 10, 15, 20, 25, 30, 40, 50, 60, 70, 80, 90, 100, 120, 130, or more) small molecules or metabolites in a sample, for example one or more of those listed in Tables 8 and 9 and FIG. 19A-W, or any combination thereof. In particular examples, the methods include determining the level of one or more markers of glycolysis or gluconeogenesis (such as glucose, lactate, pyruvate, fructose 6-phosphate, and/or glucose 6-phosphate), branched chain amino acids (such as valine, lysine, and/or leucine) or metabolites or side-products of branched chain amino acid synthesis (such as alpha-ketoglutarate, glutamine, and/or glutamate), oxidative stress (such as ascorbate), or lipoxygenase activity (such as 12-HETE and/or 15-HETE) from a sample from an organ (such as a liver) or from a subject. In other examples, the methods include determining the level of one or more of ribose, ribulose, glycolate, oxidized homo-glutathione (GSSG), and/or ethanolamine from a sample from an organ (such as a liver) or from a subject. It is then assessed as to whether the level of the one or more biomarker differs from a control sample or a reference value. A change in the amount of one or more biomarkers in the sample, as compared to control or reference value indicates that the organ or subject is at risk for (or has) organ dysfunction. In some examples, a decrease in the levels of biomarkers of glycolysis, branched chain amino acids or branched chain amino acid synthesis, or lipoxygenase activity compared to a healthy control or reference indicates that the organ or subject is at risk for (or has) organ dysfunction (for example, liver dysfunction). In other examples, an increase in the levels of biomarkers of oxidative stress or lipoxygenase activity compared to a healthy control or reference value indicates that the organ or subject is at risk for (or has) organ dysfunction (for example, liver dysfunction).

In particular examples, a decrease in one or more of glucose, lactate, pyruvate, fructose 6-phosphate, glucose 6-phosphate, valine, isoleucine, leucine, alpha-ketoglutarate, glutamate, or 15-HETE as compared to a healthy control or reference value indicates that the organ or subject is at risk for (or has) organ dysfunction. In other particular examples, an increase in ascorbate or 12-HETE as compared to a healthy control or reference value indicates that the organ or subject is at risk for (or has) organ dysfunction. Additional small molecules associated with organ function (particularly liver function) are shown in FIG. 19A-19W. These molecules may be particularly suitable for identifying subjects at risk for (or having) liver dysfunction and/or determining the severity of the liver dysfunction and/or the necessity of imminent organ transplantation.

In other examples, the samples are analyzed for one or more of ribulose, ribose, oxidized homo-glutathione (GSSG), glycolate (hydroxyacetate), xylonate, and/or ethanolamine. For example, a decrease in ribulose, ribose, and/or glycolate and/or an increase in GSSG and/or ethanolamine compared to a control (for example a healthy organ) indicates that an organ has or is predicted to have poor function.

In other embodiments, the methods include determining the level of gene expression of one or more genes in the sample (such as 2, 3, 4, 5, 5, 10, 15, 20, 25, 30, 40, 50, 60, 70, 80, 90, 100, 120, 130, or more), for example, one or more of those genes listed in FIGS. 5-7 and 10, or any combination thereof. In some examples, the methods include determining the level of one or more genes associated with cell proliferation (such as Jun, NFκB, Gadd45(3, and/or Gadd45a), general metabolic function and free-radical defenses (such as superoxide dismutase 1 and/or acyl coenzyme A synthetase), and/or differentiation (such as albumin, apolipoproteins, and/or cytochrome P450). These genes may be particularly suitable for identifying subjects at risk for (or having) liver dysfunction and/or determining the severity of the liver dysfunction and/or the necessity of imminent organ transplantation. One of ordinary skill in the art can identify genes associated with cell proliferation and/or differentiation in other tissues or organs.

In particular examples, a decrease in one or more of Jun, NFκB, apolipoprotein A-II, superoxide dismutase 1, acyl coenzyme A synthetase, thrombospondin 1, prothymosin, alpha, cytochrome c oxidase subunit II, and/or alpha-2-macroglobulin as compared to a healthy control or reference value indicates that the organ or subject is at risk for (or has) organ dysfunction. Additional genes associated with organ function (particularly liver function) are shown in FIGS. 5-7 and 10.

In other embodiments, the methods include determining the level of one or more proteins in the sample (such as 2, 3, 4, 5, 5, 10, 15, 20, 25, 30, 40, 50, 60, 70, 80, 90, 100, 120, 130, or more), for example, one or more proteins encoded by the genes shown in FIGS. 5-7 and 10, or any combination thereof. In other examples, the methods include determining the level of cytokines and/or chemokines (for example, one or more of interferon-α, interferon-γ, interleukin-10, interleukin-12/23 (p40), interleukin-1b, interleukin-4, interleukin-6, interleukin-8, and/or tumor necrosis factor-α). In particular examples, an increase in one or more of IFN-α, TNF-α, IFN-γ, IL-4, IL-1β, and/or IL-12/IL-23(p40) for example as compared to a healthy control or reference value indicates that the organ or subject is at risk for (or has) organ dysfunction. In other examples, one or more of VEGF, TGF-β, ERK/MAPK, ErbB, FAK, HGF, p53, insulin receptor, PI3K/AKT, PDGF, FGF, EGF, and NF-κB are analyzed. For example, an increase in one or more of VEGF, TGF-β, ERK/MAPK, ErbB, FAK, HGF, p53, insulin receptor, PI3K/AKT, PDGF, FGF, EGF, and NF-κB gene or protein expression (for example compared to a control, such as a dysfunctional organ) indicates good organ function. These proteins may be particularly suitable for identifying subjects at risk for (or having) liver dysfunction and/or determining the severity of the liver dysfunction and/or the necessity of imminent organ transplantation.

In still further embodiments, organ function can be measured by production of a fluid, such as bile or urine. In some examples, a decrease in bile production by a liver indicates that the liver is at risk for, or has, dysfunction. In other examples, a decrease in urine production by a kidney indicates that the kidney is at risk for, or has, dysfunction. In further examples, organ function can be measured by the presence or amount of one or more components in a fluid, such as bile or urine. In some examples, production of hydrophilic bile (e.g., decreased levels of taurodeoxycholate) indicates that the liver is predicted to have, or has, good function, while production of hydrophobic bile (e.g., increased levels of glycocholenate sulfate) indicates that the liver is at risk for, or has, dysfunction. In other examples, an increase in hydrophobic bile salts (e.g., glycochenodeoxycholate) indicates that the liver is at risk for, or has, dysfunction, while production of hydrophilic bile salts (e.g., ursodoxycholic acid) indicates that the liver is predicted to have, or has, good function.

In some embodiments, the methods include selecting an organ for transplantation, for example, an organ that is predicted to have good function (or an organ that is not predicted to be at risk for or have dysfunction). In one example, an organ that is a candidate for transplantation is machine perfused and samples are collected. The samples are rapidly analyzed (for example in a few hours) and if the organ is predicted to be at risk for or have organ dysfunction, the organ is not utilized for transplantation. If the organ is predicted to have good function, the organ is utilized for transplantation into a transplant recipient.

In some embodiments, the methods include administering a treatment to a subject identified as being at risk for or having organ dysfunction. One of ordinary skill in the art, such as a clinician, can identify an appropriate treatment for the subject based on the organ, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, and severity of the condition of the subject undergoing therapy. In one example, liver dysfunction includes enhanced metabolic pathway to gluconeogenesis leading to steatosis, and therapies administered to a subject with liver dysfunction could include intervention in the metabolic pathway (e.g., diet and medication) to reverse the dysfunction. In another example, kidney dysfunction includes decreased glomerular filtration rate due to progressive vasospasm of the afferent arterioles within the nephron and therapies could include identification of vasogenic factors (vasospasm) and amelioration of this condition as precursor of progressive hypertension

IV. Methods of Determining Presence or Amount of Biomarkers in a Sample

A. Nucleic Acids

In some embodiments, the methods disclosed herein include detecting presence and/or amount of one or more nucleic acids (such as DNA, RNA, mRNA, or miRNA) in a sample from a tissue, organ, organ perfusate, fluid, or subject. In some examples, nucleic acids are isolated from the sample. Methods of isolating nucleic acids are known to one of skill in the art. For instance, rapid nucleic acid preparation can be performed using a commercially available kit (such as kits and/or instruments from Qiagen (such as DNEasy®, RNEasy®, or miRNEasy® kits), Life Technologies (such as ChargeSwitch® gDNA, ChargeSwitch® RNA, or mirVana™ kits) Roche Applied Science (such as MagNA Pure kits and instruments), Thermo Scientific (KingFisher mL), bioMérieux (Nuclisens® NASBA Diagnostics), or Epicentre (Masterpure™ kits)). In other examples, the nucleic acids may be extracted using guanidinium isothiocyanate, such as single-step isolation by acid guanidinium isothiocyanate-phenol-chloroform extraction (Chomczynski et al. Anal. Biochem. 162:156-159, 1987). The sample can be used directly or can be processed, such as by adding solvents, preservatives, buffers, or other compounds or substances. In addition, the nucleic acids may be processed further to produce a nucleic acid suitable for various assays, for example, reverse transcribing mRNA to cDNA. One of skill in the art can identify additional reagents and methods that can be used for nucleic acid purification or preparation for use in the methods disclosed herein.

Methods for analyzing nucleic acids in a sample (for example, detecting amount and/or changes in gene expression) are known to one of skill in the art and include, but are not limited to, Southern blotting, Northern blotting, in situ hybridization, RNase protection, subtractive hybridization, differential display, antibody-based methods (such as use of antibodies that can recognize specific duplexes, including DNA duplexes, RNA duplexes, and DNA-RNA hybrid duplexes or DNA-protein duplexes), microarray-based methods, amplification-based methods, and sequencing-based methods. One of skill in the art can identify additional techniques that can be used to analyze gene expression, and it is to be understood that gene expression detection methods for use in the present disclosure include those developed in the future.

In some examples, gene expression (such as presence and/or amount of RNA, mRNA, and/or miRNA) is identified or confirmed using microarray techniques. Thus, expression of one or more genes (or an expression profile) can be measured using microarray technology. In this method, nucleic acids of interest (including for example, cDNAs and/or oligonucleotides) are plated, or arrayed, on a microchip substrate. The arrayed nucleic acids are then hybridized with isolated nucleic acids (such as cDNA or mRNA) prepared or isolated from the sample. Hybridization of the isolated nucleic acids with the arrayed nucleic acids is detected, for example, based on identification of a label associated with a nucleic acid that is detected at an addressable location non the array. Microarray analysis can be performed by commercially available equipment, following the manufacturer's protocols, such as are supplied with Affymetrix GeneChip® technology (Affymetrix, Santa Clara, Calif.), or Agilent's microarray technology (Agilent Technologies, Santa Clara, Calif.).

In further examples, nucleic acids are analyzed by amplification techniques including, polymerase chain reaction (PCR), quantitative real-time PCR, reverse transcription PCR (RT-PCR), quantitative RT-PCR (qRT-PCR), digital PCR, strand displacement amplification (see U.S. Pat. No. 5,744,311); transcription-free isothermal amplification (see U.S. Pat. No. 6,033,881); transcription-mediated amplification (TMA); repair chain reaction amplification (see WO 90/01069); ligase chain reaction amplification (see EP-A-320 308); gap filling ligase chain reaction amplification (see U.S. Pat. No. 5,427,930); coupled ligase detection and PCR (see U.S. Pat. No. 6,027,889); and NASBA™ RNA transcription-free amplification (see U.S. Pat. No. 6,025,134).

In other examples, gene expression is detected using sequencing techniques. Representative methods for sequencing-based gene expression analysis include Serial Analysis of Gene Expression (SAGE; Velculescu et al., Science 270:484-487, 1995), 454 pyrosequencing (Tones et al., Genome Res. 18:172-177, 2008), RNA-seq (Wang et al., Nat Rev. Genet. 10:57-63. 2009), and gene expression analysis by massively parallel signature sequencing (MPSS; Brenner et al., Nat. Biotechnol. 18:630-634, 2000).

B. Proteins

In some embodiments, the methods disclosed herein include detecting presence and/or amount of one or more proteins or fragments thereof in a sample from a tissue, organ, organ perfusate, fluid, or subject. In some examples, the samples are used without processing. In other examples, the samples are processed prior to protein analysis, for example by adding one or more components (such as detergents, buffers, or salts), lysis (if cells are present), and/or fractionation.

Any standard immunoassay format (such as ELISA, Western blot, or radioimmunoassay) can be used to measure protein levels. Immunohistochemical techniques can also be utilized for protein detection and quantification. General guidance regarding such techniques can be found in Bancroft and Stevens (Theory and Practice of Histological Techniques, Churchill Livingstone, 1982) and Ausubel et al. (Current Protocols in Molecular Biology, John Wiley & Sons, New York, 1998).

In some examples, protein (or fragments thereof) are detected in a sample using mass spectrometry methods, such as mass spectrometry (MS), tandem MS (MS/MS), matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) MS, or electrospray ionization (ESI)-MS. In some examples, the sample may be subjected to a separation technique, such as liquid chromatography or 2-dimensional electrophoresis prior to MS analysis. Semi-quantitative or quantitative MS methods are also available. (See, e.g., Gygi et al., Nat. Biotechnol. 17:994-999, 1999; Aebersold, J. Inf. Dis. 187:S315-S320, 2003.) In other examples, proteins or fragments thereof are identified or confirmed using microarray techniques. In this method, protein of interest or fragments thereof are plated, or arrayed, on a microchip substrate. The arrayed proteins are then contacted with proteins prepared or isolated from the sample. Binding of the proteins from the sample with the arrayed proteins is detected, for example, based on contacting with a label and localization to an addressable location on the array. Microarray analysis can be performed by commercially available equipment, following the manufacturer's protocols, such as are supplied with ProtoArray® protein microarray (Life Technologies) or HuProt™ arrays (Cambridge Protein Arrays).

In other examples, a bead-based assay is used to measure proteins in the sample. Such assays typically include beads coated with a capture antibody for a specific analyte. The beads are incubated with proteins prepared or isolated from a sample and binding of a protein to a bead is detected, for example using flow cytometry. Bead-based assays can be multiplexed, for example by including beads with different fluorescence intensities, each coated with an antibody specific for a specific protein. The presence and identity of different proteins can thus be detected, based on the fluorescence of the particular bead bound by a protein. Bead-based assays are commercially available (such as the Luminex xMAP® technology or the BD Biosciences Cytometric Bead Array).

One of skill in the art can identify additional techniques that can be used to analyze proteins in a sample, and it is to be understood that protein detection methods for use in the present disclosure include those developed in the future.

C. Small Molecules/Metabolites

The small molecule profile of a sample can be obtained through, for example, a single technique or a combination of techniques for separating and/or identifying small molecules known in the art. Examples of separation and analytical techniques which can be used to separate and identify the compounds of the small molecule profiles include: HPLC, TLC, electrochemical analysis, mass spectroscopy (for example, GC/MS or LC/MS/MS), refractive index spectroscopy (RI), Ultra-Violet spectroscopy (UV), fluorescent analysis, radiochemical analysis, Near-InfraRed spectroscopy (Near-IR), Nuclear Magnetic Resonance spectroscopy (NMR), Light Scattering analysis (LS) and other methods known in the art. One of skill in the art can identify additional techniques that can be used to analyze small molecules, and it is to be understood that detection methods for use in the present disclosure include those developed in the future.

The methods can be used to detect electrically neutral as well as electrochemically active compounds. Detection and analytical techniques can be arranged in parallel to optimize the number of molecules identified. In some examples, analysis of the small molecule profile of a sample includes analysis by a commercial provider, such as Metabolon (Durham, N.C.). In particular non-limiting examples, the small molecule profile is analyzed in perfusate from an ex vivo perfused organ, bile, or urine.

The present disclosure is illustrated by the following non-limiting Examples.

Example 1 Experimental Model

This example describes the liver transplantation model used for sample collection for further analysis. The machine perfusion system and oxygen carrier perfusion solution are described in related U.S. Provisional Patent Application No. 61/713,284, filed Oct. 12, 2012, and International Pat. Publ. No. WO 2014/059316, both of which are incorporated herein by reference in their entirety.

Two groups of 6 swine underwent orthotopic liver transplantation after a period of 9 hours of preservation (cold ischemia time (CIT)=9 hours). Both groups had a 5 day follow up while receiving Tacrolimus (0.3 mg/kg) as their primary immunosuppressive therapy. All surviving animals underwent an end-study necropsy on the 5^(th) post-operative day. This challenging swine model (CIT=9 hours) has been consistently demonstrated as having a 70-100% mortality in 5-7 days.

The control group had their liver allografts preserved with CSP (University of Wisconsin solution (UW) at 4° C. under anoxic conditions). The study group had their liver allografts preserved with machine perfusion (MP; Organ Assist, Groningen, Netherlands) and a newly developed hemoglobin-based oxygen carrier (HBOC) solution (HEMOPURE (OPK Biotech, Cambridge, Mass.) mixed with Belzer Machine Perfusion Solution (BMPS) at 1:3). The MP livers underwent continuous perfusion under dual pressure (continuous at the portal vein and pulsatile at the hepatic artery) at 21° C. (subnormothermic conditions) and with a FiO₂ of 60%. Both groups had their liver allografts biopsied at 3, 6 and 9 hours while under preservation. Additional biopsies were taken after organ reperfusion and 5 days after the initial procedure (end-study necropsy). The schedule for sample collection is shown in Table 1. All laboratory and clinical parameters were assessed. Repeated measurements were compared between study and control groups using a mixed model with fixed effect (animal group) analysis. Continuous data were compared using either t testing or the nonparametric Wilcoxon two-sample test when appropriate.

TABLE 1 Sample collection schedule Time frame Post- reper- Group Specimen 0 3 6 9 fusion Final Control Liver X X X X X necropsy (CSP) biopsy Perfusate X X X X X X Bile † No No No No X X Study Liver X X X X X necropsy (MP) biopsy Perfusate X X X X X X Bile X X X X X X † liver allografts do not make bile during CSP

The study group (MP) had 100% survival and the control group (CSP) had a 33% survival in the 5 day period (p<0.05). The MP group had none to mild signs of reperfusion syndrome (RS) after liver allograft implantation and the CSP group had moderate to severe signs of RS. The CSP group received a significantly higher (150%, p<0.05) amount on intravenous fluids and a higher amount of vasopressors after liver allograft reperfusion while experiencing major vasodilatation as a result of the moderate to severe RS.

The CSP had a higher index of ischemia/reperfusion (IR) tissue injuries revealed by serial histological analysis during liver allograft preservation. IR injuries were considered none to mild in the MP group and moderate to severe in the CSP group (blind analysis by a selected group of transplant pathologists). All the animals that expired in the CSP experienced progressive liver allograft dysfunction leading to irreversible liver failure. The surviving CSP animals were clinically ill (renal failure, coagulopathy, progressive lactic acidosis and decreased mental status) and more ill than the MP group, who had uneventful post-operative courses.

All liver allografts were able to make bile, produce glucose and clear lactate under an extended period of time (CIT=9 hours) while under MP. Gasometric analysis of the perfusate showed high (p02>400 mm Hg) levels of oxygenation on both arterial and venous ports, low levels of CO₂ (pCO₂<18 mm Hg) and sustained pH throughout the entire perfusion protocol. Serial liver biopsies (3, 6, 9 hours) showed normal cytoarchitecture features of the hepatic parenchyma during the ex vivo MP stage. Over 16 physiological parameters were compared over the five day post-operative period and all 16 showed one-directional effect (statistically significant or not) superior to the study group compared to control. Exemplary results are shown in FIGS. 2A-2G. MP had a statistically significant (p<0.05) beneficial effect in liver allograft preservation when compared to CSP. In assumption that the MP/HBOC does not affect animal physiology post-operatively, the probability of such results is 0.5 in power 16 or p<0.004.

Tissue samples were prospectively collected for histological analysis and scoring of ischemia/reperfusion (IR) injury as shown in Table 2.

TABLE 2 Tissue sample collection for IR analysis Times Samples Notes T0 donor baseline Obtained prior to organ procurement T1 back table Obtained immediately after organ (after flush) recovery T2 3h of preservation Obtained in both groups (CSP and MP) T3 6h of preservation Obtained in both groups (CSP and MP) T4 9h of preservation Obtained in both groups (CSP and MP) TRP post reperfusion Obtained after liver implantation Necropsy 5th post-operative Obtained at the end-study necropsy day

All tissue samples were processed immediately after collection. The samples were initially divided in 2 pieces, for fresh frozen sections initially and for subsequent sections in paraffin afterwards. All tissues were processed and stained (H&E and immunohistochemistry) at the Division of Transplant Pathology, Department of Pathology, UPMC. Tissue samples for the assessment of hepatocellular injury were collected before, during, and after preservation, post-reperfusion and at end study necropsy. All liver samples were fixed in 10% buffered formalin, embedded in paraffin, sectioned (5 μm) and stained with hematoxylin and eosin for histological analyses. The severity of liver IR injuries was blindly graded by transplant pathologists using initially the International Banff Criteria (Hepatology 3:658-663, 1997). A modified Suzuki's criteria (Suzuki et al., Transplantation 55:1265-1272, 1993) was subsequently applied to quantify the IR injuries and correlate the clinical with the histopathological findings. Complete histological features were assessed both in the portal tracts and the hepatic lobules. The scored number was further weighted (none=0, mild 1-25%=1; moderate 25-50%=2 and significant >50%=3); re-scored based on its contribution to the injury while grouped into four categories and subsequently expressed as mean±standard deviation. The IR scores between the two groups were compared chronologically during liver preservation and after transplantation.

The entire histological analysis was combined within a single graphic displaying all the scores for all the samples (FIG. 3). An IR score was calculated for each time point (mean±SD) and compared longitudinally with all values obtained from the different time points. The control group (CSP) histological analysis (H&E) revealed the presence of moderate to severe IR injuries throughout the entire experiment. There was no improvement of the IR injuries after liver implantation and 67% of the animals expired within hours and/or days from liver allograft failure due to the severity of the IR injuries. The surviving animals (33%) revealed significant (p=0.01) allograft damage at the time of the elective end-study necropsy.

The study group (MP) presented none to mild IR injuries during preservation and after liver allograft implantation (TRP—reperfusion samples). The IR scores showed a progressive resolution of this transient inflammatory process over the next 5 days and the animals had 100% survival with good liver allograft function. There was a significant (p<0.05) difference between the two groups when comparing the tissue samples analyzed after the end-study necropsy. The magnitude of the IR injuries seen at the control group (CSP) were significantly higher and led to irreversible liver allograft failure and death (only 33% survival, p<0.05).

Mitochondrial isolation and respiration: Fresh tissue samples (liver biopsies from the allografts) were obtained from both groups and sent to a mitochondrial functional analysis in an oxygraph chamber. Liver mitochondria were isolated by differential centrifugation in a buffer (250 mM sucrose, 10 mM Tris, 1 mM EGTA, pH 7.4) at 4° C., as previously described. To measure respiration of isolated mitochondria, 1 mg/ml of protein was suspended in respiration buffer (120 mM KCl, 25 mM sucrose, 10 mM HEPES, 1 mM EGTA, 1 mM KH₂PO₄, 5 mM MgCl₂) in a stirred, sealed chamber fit with a Clark-type oxygen electrode (Instech Laboratories) connected to a data recording device (DATAQ Systems).

Mitochondrial function was sustained throughout the entire MP protocol with pulsatile pressures (MAP=20 mmHg) at 21° C. The oxygen delivery was estimated to be around 0.013 mlO₂/g/min and the oxygen consumption was estimated around 0.0016 mlO₂/g/min. Both the respiratory control ratio (RCR) (FIG. 4A) and ATP assays (FIG. 4B) showed uninterrupted and efficient mitochondrial function within the hepatic parenchyma while under machine perfusion at 21° C. The ROS production after liver allograft reperfusion was 2 fold higher in the CSP group (FIG. 4C).

Example 2 Microarray Analysis

This example describes microarray analysis of hepatic gene expression in the control and study transplantation groups.

Methods

Microarray analysis: Microarray analysis was performed using Affymetrix GeneChip® Porcine Genome Array (Affymetrix, Santa Clara, Calif., USA). Liver tissue samples from both groups (control=CSP and study=MP) were obtained before and after liver preservation and at the time of the end-study necropsy. Total RNA (10 μg) or mRNA (0.2 μg) was first reverse transcribed in the first-strand cDNA synthesis reaction. Following RNase H-mediated second-strand cDNA synthesis, the double-stranded cDNA was purified and served as a template in the subsequent in vitro transcription (IVT) reaction. The IVT reaction was carried out in the presence of T7 RNA Polymerase and a biotinylated nucleotide analog/ribonucleotide mix for complementary RNA (cRNA) amplification and biotin labeling. The biotinylated cRNA targets were fragmented in 1× fragmentation buffer solution provided with the GeneChip sample cleanup module (Affymetrix) at 94° C. for 35 min. A total of 10 μg of fragmented biotin-labeled cRNA per replicate in hybridization mixture then was hybridized to Porcine Genome Array from Affymetrix GeneChips™ and incubated overnight at 45° C. in Affymetrix GeneChip Hybridization Oven 640, all according to the manufacturer's instructions.

The mixture was removed 16 hours after hybridization in several cycles; the chips were washed with non-stringent buffer and stained with streptavidin-phycoerythrin antibody solution (Affymetrix) on an automated Affymetrix GeneChip Fluidic Station 450 station. The data were collected using an Affymetrix GeneChip scanner 3000. Microarray images quantified using Affymetrix GeneChip Operating Software.

Microarray data analysis: Normalization and pre-processing of data were performed using dChip software. Expression intensities were log transformed, and genes with less than 80% present calls, expression level lower than 7, or SD smaller than 0.5 were filtered out. Individual expression points of the top 100 genes that were found to be differentially regulated were fitted by statistics and the clustering pattern plotted in Microsoft Excel. The threshold line corresponds to a p value of 0.05 as calculated by the Fischer's test.

The CEL data generated by the microarray were converted using GCOS1.4 software (Affymetrix). The data generated by the Affymetrix platform contain all information required by MIAME protocols to allow the data to be submitted as needed. Details of compliance met by the CGOS1.4 software and all other programs used to convert CEL files to Excel microarray data are provided at ncbi.nlm.nih.gov/geo/info/MIAME.html.

Gene ontology analysis: The web tools DAVID (Bioinformatics enrichment tools: paths toward the comprehensive functional analysis of large gene lists) were used to identify enriched functionally related gene groups following machine perfusion.

Pathway analysis: Genes whose expression value was >2 or <2-fold compared to the control group were analyzed for identification of key canonical pathways associated with liver growth and pathology using Ingenuity Software®. The pathways that were found to be most significantly up-regulated were plotted. The biological processes that were found to be significantly affected were displayed along the y-axis. The x-axis displays the-log of p-value and was calculated by Fisher's exact test right-tailed.

Results

Hepatic gene expression was analyzed before and after preservation and at necropsy. There was a striking increase in proliferation-associated genes (Jun, Fos, ATP synthase F0 subunit 8, Apolipoprotein A-II, Metallothionein isoform, Acyl coenzyme A synthetase, Syndecan 2, Collagen Alpha 2, Prothymosin alpha) in the MP group. Many hepatocyte-differentiation genes were also upregulated, including albumin, apolipoproteins, and several cytochrome P450 (CYP) members.

The top 100 most affected genes in the MP group showed over-expression associated with general metabolic, anti-inflammatory, and regenerative functions, as well as protective mechanisms against free radicals (FIG. 5). MP also resulted in increased expression of several genes associated with entry of hepatocytes into the G1 cell cycle phase (FIG. 6). Genes associated with hepatocyte differentiation were also upregulated (FIG. 7).

Enrichment by biological process networks following MP suggested a marked up-regulation of genes related to metabolic process (34%), cellular process (25%), cell communication (17%), as well as additional effects on system process (9%), cell cycle (7%), and cell adhesion (5%) (FIG. 8). Metabolic Network Analysis (Ingenuity Software©) showed significant up-regulation of genes related to drug, amino acid, vitamin, mineral, and carbohydrate metabolism, free radical scavenging, and energy production in the MP group (FIG. 9A). Additional Biological Process Network Analysis (Ingenuity Software©) showed a significant (p<0.05) difference in gene expression related to hepatic system development and function, cellular growth and proliferation, cellular development, and cell cycle when MP was compared to CSP (FIG. 9B). Metabolic Network Analysis (Ingenuity Software©) showed significant up-regulation of genes related to drug, amino acid, vitamin, mineral, and carbohydrate metabolism, free radical scavenging, and energy production in the MP group. Thus, MP with full oxygenation enhances signaling pathways for HGF, EGF, TGF-β, ErbB and PI3K/AKT among others, and triggers proliferative and regenerative transcriptional pathways when compared to CSP (FIG. 10).

Example 3 Cytokine Profiling

This example describes the cytokine profile of tissue samples from control and study group animals.

Additional tissue assays were performed with Affymetrix pig 9 plex Luminex analysis. Approximately 50 mg of the tissue was transferred to a 2.0 ml microcentrifuge tube containing 1 ml of lxBioSource tissue extraction reagent (San Diego, Calif.) (Catalog Number FNN0071) supplemented with 10 ml of 100 mM phenylmethanesulfonyl fluoride in ethanol as a protease inhibitor. The tissue was homogenized for 15-30 sec until the sample was in a consistent solution. The sample was placed on ice, if processing multiple samples, and was then centrifuged at 4° C. for 10 min at 10,000×g. After centrifugation, the supernatant was collected and placed in a new microcentrifuge tube, placed on ice, and assayed for protein content using the bicinchoninic acid (BCA) protein assay (Pierce, Rockford, Ill.) using the manufacturer's protocol. Depending on tissue type, a 1:5 or 1:10 dilution was necessary before addition of samples to the BCA assay.

Pig cytokines (INF-α, IFN-γ, IL-10, IL-12/IL-23 (p40), IL-1β, IL-4, IL-6, IL-8 and TNF-α) were detected using a Luminex™ 100 IS apparatus using the BioSource International Pig 9 plex LUMINEX beadset. Cytokine levels are presented as mean±SEM. Differences between the levels of a given cytokine measured in flash-frozen tissue vs. RNALATER™-preserved tissue were assessed by Student's t-test analysis using SigmaStat™ software (SPSS, Chicago, Ill.). Cytokine levels are shown in FIGS. 11-16. Multiple protein-level inflammatory mediators in both tissue and perfusate were significantly (p<0.05) different between groups. MP was associated with downregulation of both type I (IFN-α) and type II (IFN-γ) interferons, consistent with prior studies that showed elevated inflammation and apoptosis subsequent to IR due to the IRF-1 pathway in CSP. The suggestion of a protective mechanism provided by sustainable oxygenation ex vivo was further reinforced by the significant difference in IL-4 levels in the tissues of the MP group. MP was associated with downregulated TNF-α levels in liver tissue when compared to CSP. This detrimental TNF-α activation pathway seen in the CSP group was further corroborated by higher levels of additional Kupffer cells mediators IL-1(3 and IL-12/IL-23 p40 found on liver tissues. MP down-regulated IL-2 expression progressively during preservation when compared to CSP, which might contribute to lower T cell activation after organ implantation.

Example 4 Metabolomic Analysis

This example describes the metabolomics analysis of samples from control and study group animals.

Metabolomic analysis was performed on 27 perfusate and 31 bile samples (Tables 3 and 4, respectively) by Metabolon (Durham, N.C.). Following receipt, samples were inventoried, and immediately stored at −80° C. At the time of analysis, samples were extracted and prepared for analysis using Metabolon's standard solvent extraction method. The extracted samples were split into equal parts for analysis on the GC/MS and LC/MS/MS platforms. Also included were several technical replicate samples created from a homogeneous pool containing a small amount of all study samples.

TABLE 3 Liver Perfusate samples Time Point Treatment 0 h 6 h 9 h Cold static perfusion in UW n = 2 n = 4 n = 4 buffer (UW/CSP) Machine perfusion in HBOC n = 6 n = 6 n = 5 buffer (HBOC/MP)

TABLE 4 Bile samples Time Point Treatment 0-4 h 16-24 h 64-72 h Cold static perfusion in UW n = 4 n = 5 n = 4 buffer (UW/CSP) Machine perfusion in HBOC n = 6 n = 6 n = 6 buffer (HBOC/MP)

TABLE 5 Data Quality: Instrument and Process Variability Liver Perfusate Bile QC Sample Measurement Median RSD Median RSD Internal Instrument  6%  8% Standards Variability Endogenous Total Process 10% 11% Biochemicals Variability

Instrument variability was determined by calculating the median relative standard deviation (RSD) for the internal standards that were added to each sample prior to injection into the mass spectrometers. Overall process variability was determined by calculating the median RSD for all endogenous metabolites (non-instrument standards) present in 100% of the Client Matrix samples, which are technical replicates of pooled client samples. Values for instrument and process variability met Metabolon's acceptance criteria as shown in the Table 5, above. There were 223 compounds of known identity (named biochemicals) in liver perfusate and 377 named biochemicals in bile. Following log transformation and imputation of missing values, if any, with the minimum observed value for each compound, Welch's two-sample t-tests were used to identify biochemicals that differed significantly between experimental groups. A summary of the numbers of biochemicals that achieved statistical significance (p<0.05), as well as those approaching significance (0.05<p<0.10), is shown below (Tables 6 and 7).

TABLE 6 Summary of biochemicals that differed in liver perfusate samples between groups Statistical Comparisons (Perfusate) Total Total bio- bio- Bio- chemicals Bio- Welch′s Two- chemicals chemicals 0.05 < chemicals Sample t-Test p ≤ 0.05 (↑↓) p < 0.10 (↑↓) HBOC/MP 0 h 49 24 | 25 19  4 | 15 UW/CSP 0 h HBOC/MP 6 h 140 89 | 51 15 9 | 6 UW/CSP 6 h HBOC/MP 9 h 121 81 | 40 25 11 | 14 UW/CSP 9 h UW/CSP 6 h 17 16 | 1  18 17 | 1  UW/CSP 0 h UW/CSP 9 h 22 22 | 0  14 12 | 2  UW/CSP 0 h UW/CSP 9 h 2 0 | 2  4 1 | 3 UW/CSP 6 h HBOC/MP 6 h 171 153 | 18  12 11 | 1  HBOC/MP 0 h HBOC/MP 9 h 154 137 | 17  14 14 | 0  HBOC/MP 0 h HBOC/MP 9 h 17 9 | 8 10 5 | 5 HBOC/MP 6 h

TABLE 7 Summary of biochemicals that differed in bile samples between groups Statistical Comparisons (Bile) Total Total bio- bio- Bio- chemicals Bio- Welch′s Two- chemicals chemicals 0.05 < chemicals Sample t-Test p ≤ 0.05 (↑↓) p < 0.10 (↑↓) HBOC/MP 0-4 68 35 | 33 26 10 | 16 UW/CSP 0-4 HBOC/MP 16- 68 14 | 54 37 15 | 22 24 UW/CSP 16-24 HBOC/MP 64- 39 35 | 4  31 18 | 13 72 UW/CSP 64-72 UW/CSP 16-24 88 58 | 30 32 17 | 15 UW/CSP 0-4 UW/CSP 64-72 82  7 | 75 33  7 | 26 UW/CSP 0-4 UW/CSP 64-72 63  2 | 61 40  1 | 39 UW/CSP 16-24 HBOC/MP 16- 134 58 | 76 26 10 | 16 24 HBOC/MP 0-4 HBOC/MP 64- 176  35 | 141 28  7 | 21 72 HBOC/MP 0-4 HBOC/MP 64- 68  3 | 65 32  4 | 28 72 HBOC/MP 16- 24

Perfusate Results MP with HBOC had a bigger impact on the metabolic profile over time than cold static perfusion (CSP). Perfusate profiling revealed differences in stress responses over time between the two preservation conditions. Biochemicals that provide insight into oxidative, inflammatory, and energy stress were among those showing a strong separation between perfusate profiles from the two preservation conditions. Possible signs of energy stress and purine nucleotide breakdown were noted in the UW/CSP-preserved livers as indicated by the significantly higher levels of AMP, nucleosides adenosine, guanosine, and inosine, as well as the inosine deamination product hypoxanthine. Evidence of lipoxygenase activity was observed and differed by preservation method. Altogether this suggested that inflammation was greater in the UW/CSP than HBOC/MP samples. The glucose-amino acid cycle and branched-chain amino acid mobilization were markedly elevated in HBOC/MP samples. Branched-chain amino acid (BCAA) oxidation showed a strong differential increase in HBOC/MP perfusates at the 6 and 9 h time points (FIG. 17A-17C). In addition, byproducts of the Krebs cycle showed significant differences between the groups (FIGS. 18A-18B). These could potentially be used as a marker for adequate aerobic metabolism in tissues experiencing previous ischemic insult.

Bile Results Bile acid release during perfusion was suppressed but sterol synthesis after transplant was increased in the HBOC/MP group. Five bile acid conjugates were detected in UW/CSP liver perfusates but were not detected or detected at very low levels in HBOC/MP perfusates, which reinforces the argument towards the inability to sustain effective bile acid conjugation during CSP. MP-treated livers made but did not release glycochenodeoxycholate during perfusion but resumed its secretion almost immediately following liver reperfusion. Although campesterol levels in both treatment groups started out similarly, they remained stable in bile samples collected from MP-preserved livers but rapidly tapered off in bile from UW/CSP-preserved livers. MP-preserved livers were able to adequately support bile-mediated nutrient extraction whereas UW/CSP-preserved livers appeared to be less capable of doing so.

After this initial analysis, biomarkers have been grouped by divergent biochemical pathways within known molecular groups (Tables 8 and 9). Analysis of additional markers in control and study group liver perfusate is shown in FIGS. 19A-19W.

TABLE 8 Biomarkers in perfusate, grouped by divergent pathways within known molecular groups/pathways Super Sub Plat- Comp Pathway Pathway Biochemical Name form ID Amino Glycine, glycine GC/MS 11777 acid serine N-acetylglycine GC/MS 27710 and beta-hydroxypyruvate GC/MS 15686 threonine serine GC/MS 1648 metabolism threonine GC/MS 1284 betaine LC/MS 3141 pos Alanine and aspartate GC/MS 15996 aspartate beta-alanine GC/MS 55 metabolism alanine GC/MS 1126 Glutamate glutamate GC/MS 57 metabolism 4-hydroxyglutamate GC/MS 40499 glutamine GC/MS 1647 pyroglutamine* LC/MS 32672 pos gamma-aminobutyrate GC/MS 1416 (GABA) Histidine histidine LC/MS 59 metabolism neg Lysine lysine GC/MS 1301 metabolism 2-aminoadipate GC/MS 6146 Phenyl- phenylalanine LC/MS 64 alanine & pos tyrosine tyrosine LC/MS 1299 metabolism pos phenylacetylglycine LC/MS 33945 neg phenol sulfate LC/MS 32553 neg 5-hydroxymethyl-2- GC/MS 42040 furoic acid Tryptophan tryptophan LC/MS 54 metabolism pos C-glycosyltryptophan* LC/MS 32675 pos 3-indoxyl sulfate LC/MS 27672 neg Valine, 3-methyl-2-oxobutyrate LC/MS 21047 leucine neg and 3-methyl-2-oxovalerate LC/MS 15676 isoleucine neg metabolism beta-hydroxyisovalerate GC/MS 12129 isoleucine LC/MS 1125 pos leucine LC/MS 60 pos tigloylglycine LC/MS 1598 pos valine LC/MS 1649 pos 4-methyl-2- LC/MS 22116 oxopentanoate neg isovalerylglycine LC/MS 35107 neg 2-methylbutyrylglycine LC/MS 31928 neg 3-methylglutaryl- LC/MS 37060 carnitine (C6) pos Cysteine, cysteine GC/MS 31453 methionine, N-acetylcysteine LC/MS 1586 SAM, pos taurine S-methylcysteine GC/MS 40262 metabolism cystine GC/MS 39512 hypotaurine GC/MS 590 taurine GC/MS 2125 S-adenosylhomo- LC/MS 15948 cysteine (SAH) neg methionine LC/MS 1302 pos 2-hydroxybutyrate GC/MS 21044 (AHB) 4-methylthio-2- LC/MS 40732 oxobutanoate neg Urea cycle; ornithine GC/MS 1493 arginine-, urea GC/MS 1670 proline-, proline LC/MS 1898 metabolism pos Creatine creatine LC/MS 27718 metabolism pos creatinine LC/MS 513 pos Butanoate 2-aminobutyrate GC/MS 1577 metabolism Polyamine 5-methylthioadenosine LC/MS 1419 metabolism (MTA) pos putrescine GC/MS 1408 spermidine GC/MS 485 spermine LC/MS 603 pos Glutathione glutathione, reduced LC/MS 2127 metabolism (GSH) pos S-methylglutathione LC/MS 33944 pos 5-oxoproline LC/MS 1494 neg glutathione, oxidized LC/MS 38783 (GSSG) pos cysteine-glutathione LC/MS 35159 disulfide pos ophthalmate LC/MS 34592 pos Peptide Dipeptide glycylglycine GC/MS 21030 cysteinylglycine GC/MS 35637 Dipeptide carnosine LC/MS 1768 derivative neg gamma- gamma- LC/MS 32393 glutamyl glutamylvaline pos gamma- LC/MS 18369 glutamylleucine pos gamma-glutamyl- LC/MS 34456 isoleucine* pos gamma-glutamyl- LC/MS 37539 methionine pos gamma-glutamyl- LC/MS 36738 glutamate pos gamma-glutamyl- LC/MS 33422 phenylalanine pos gamma-glutamyl- LC/MS 2734 tyrosine pos Carbo- Aminosugars erythronate* GC/MS 33477 hydrate metabolism Fructose, fructose GC/MS 577 mannose, galactitol (dulcitol) GC/MS 1117 galactose, galactose GC/MS 12055 starch, maltose GC/MS 15806 and sucrose mannose GC/MS 584 metabolism mannose-6-phosphate GC/MS 1469 Isobar: sorbitol, LC/MS 33004 mannitol pos sucrose LC/MS 1519 neg maltotriose LC/MS 15913 neg raffinose LC/MS 586 neg verbascose LC/MS 37132 neg palatinitol GC/MS 37469 Oligo- lactobionate GC/MS 20685 saccharide Glycolysis, glycerate GC/MS 1572 gluconeo- glucose-6-phosphate GC/MS 31260 genesis, (G6P) pyruvate glucose GC/MS 31263 metabolism fructose-6-phosphate GC/MS 12021 3-phosphoglycerate GC/MS 1414 dihydroxyacetone GC/MS 15522 phosphate (DHAP) 1,3-dihydroxyacetone GC/MS 35963 phosphoenolpyruvate GC/MS 597 (PEP) pyruvate GC/MS 599 lactate GC/MS 527 Glyoxylate oxalate (ethanedioate) GC/MS 20694 and dicarbo- xylate metabolism Nucleotide 6-phosphogluconate GC/MS 15442 sugars, arabitol GC/MS 38075 pentose ribitol GC/MS 15772 metabolism threitol GC/MS 35854 sedoheptulose-7- GC/MS 35649 phosphate gluconate GC/MS 587 ribose GC/MS 12080 ribose 5-phosphate GC/MS 561 ribose 1-phosphate GC/MS 1763 ribulose GC/MS 35855 Isobar: ribulose 5- GC/MS 37288 phosphate, xylulose 5-phosphate xylitol GC/MS 4966 xylose GC/MS 15835 xylonate GC/MS 35638 xylulose GC/MS 18344 Secondary Advanced erythrulose GC/MS 37427 Metabolism glycation end-product Energy Krebs cycle citrate LC/MS 1564 neg alpha-ketoglutarate GC/MS 33453 succinate GC/MS 1437 fumarate GC/MS 1643 malate GC/MS 1303 Oxidative acetylphosphate GC/MS 15488 phosphoryl- phosphate GC/MS 11438 ation pyrophosphate (PPi) GC/MS 2078 linoleate (18:2n6) LC/MS 1105 neg Lipid Essential linolenate [alpha or LC/MS 34035 fatty acid gamma; (18:3n3 or 6)] neg dihomo-linolenate LC/MS 35718 (20:3n3 or n6) neg eicosapentaenoate LC/MS 18467 (EPA; 20:5n3) neg docosapentaenoate LC/MS 32504 (n3 DPA; 22:5n3) neg docosahexaenoate LC/MS 19323 (DHA; 22:6n3) neg Medium caproate (6:0) LC/MS 32489 chain neg fatty acid caprylate (8:0) LC/MS 32492 neg 2-aminoheptanoic acid LC/MS 43761 pos Long chain oleate (18:1 n9) GC/MS 1359 fatty acid arachidate (20:0) LC/MS 44679 neg eicosenoate LC/MS 33587 (20:1 n9 or 11) neg dihomo-linoleate LC/MS 17805 (20:2n6) neg mead acid (20:3n9) LC/MS 35174 neg arachidonate (20:4n6) LC/MS 1110 neg Fatty acid, 3-hydroxypropanoate GC/MS 42103 mono- 4-hydroxybutyrate (GHB) GC/MS 34585 hydroxy 13-HODE + 9-HODE LC/MS 37752 neg Fatty acid, 4-hydroxy-2-oxoglutaric GC/MS 40062 dicarbo- acid xylate hexadecanedioate LC/MS 35678 neg octadecanedioate LC/MS 36754 neg Eicosanoid 12-HETE LC/MS 37536 neg 15-HETE LC/MS 37538 neg Fatty acid propionylcarnitine LC/MS 32452 metabolism pos (also BCAA propionylglycine LC/MS 31932 metabolism) neg butyrylcarnitine LC/MS 32412 pos Carnitine carnitine LC/MS 15500 metabolism pos acetylcamitine LC/MS 32198 pos Bile acid glycocholate LC/MS 18476 metabolism neg taurocholate LC/MS 18497 neg glycochenodeoxycholate LC/MS 32346 neg glycolithocholate LC/MS 31912 neg taurolithocholate LC/MS 31889 neg glycohyodeoxycholic LC/MS 43501 acid pos Glycerolipid ethanolamine GC/MS 34285 metabolism phosphoethanolamine GC/MS 12102 choline LC/MS 15506 pos glycerol 3-phosphate GC/MS 15365 (G3P) glycerophosphoryl- LC/MS 15990 choline (GPC) pos Inositol myo-inositol GC/MS 19934 metabolism scyllo-inositol GC/MS 32379 Ketone 3-hydroxybutyrate GC/MS 542 bodies (BHBA) acetoacetate GC/MS 33963 1,2-propanediol GC/MS 38002 Lysolipid 1-arachidonoylglycero- LC/MS 35186 phosphoethanol amine* neg 1-palmitoylglycero- LC/MS 33955 phosphocholine (16:0) neg 1-oleoylglycerophos- LC/MS 33960 phocholine (18:1) neg 1-linoleoylglycero- LC/MS 34419 phosphocholine (18:2n6) neg 2-linoleoylglycero- LC/MS 38087 phosphocholine* neg 1-arachidonoylglycero- LC/MS 34061 phosphocholine (20:4n6)* neg Monoacyl- 1-palmitoylglycerol GC/MS 21127 glycerol (1-monopalmitin) Sphingolipid palmitoyl sphingomyelin GC/MS 37506 Sterol/ pregnanediol-3- LC/MS 40708 Steroid glucuronide neg Nucleotide Purine xanthine LC/MS 3147 metabolism, neg (hypo) xanthosine LC/MS 15136 xanthine/ neg inosine hypoxan thine LC/MS 3127 containing neg inosine LC/MS 1123 neg 2′-deoxyinosine LC/MS 15076 neg Purine adenine LC/MS 554 metabolism, pos adenine adenosine LC/MS 555 containing pos N6-methyladenosine LC/MS 37114 pos adenosine 5′- LC/MS 32342 monophosphate (AMP) pos adenosine-2′,3′-cyclic LC/MS 37467 monophosphate pos N6,N6- LC/MS 42081 dimethyladenosine pos Purine guanine LC/MS 32352 metabolism, pos guanine guanosine LC/MS 1573 containing neg isoguanine GC/MS 42958 Purine urate GC/MS 1604 metabolism, allantoin GC/MS 1107 urate metabolism Pyrimidine cytidine LC/MS 514 metabolism, neg cytidine containing Pyrimidine 3-aminoisobutyrate GC/MS 1566 metabolism, thymine containing; Valine, leucine and isoleucine metabolism/ Pyrimidine uracil GC/MS 605 metabolism, uridine LC/MS 606 uracil neg containing Purine and methyl phosphate GC/MS 37070 pyrimidine metabolism Cofactors Ascorbate ascorbate (Vitamin C) GC/MS 1640 and and aldarate threonate GC/MS 27738 vitamins metabolism arabonate GC/MS 37516 Hemoglobin heme LC/MS 41754 and neg porphyrin L-urobilin LC/MS 40173 metabolism pos Nicotinate nicotinamide LC/MS 594 and pos nicotinamide N1-Methyl-2-pyridone- LC/MS 40469 metabolism 5-carboxamide pos Pantothenate pantothenate LC/MS 1508 and CoA neg metabolism Riboflavin riboflavin (Vitamin B2) LC/MS 1827 metabolism pos Xeno- Benzoate hippurate LC/MS 15753 biotics metabolism neg 2-hydroxyhippurate LC/MS 18281 (salicylurate) neg Chemical glycolate (hydroxyacetate) GC/MS 15737 2-hydroxyisobutyrate GC/MS 22030 glycerol 2-phosphate GC/MS 27728 HEPES LC/MS 21248 pos trizma acetate GC/MS 20710 2-ethylhexanoate (isobar LC/MS 35490 with 2-propylpentanoate) neg ricinoleic acid LC/MS 37464 neg Drug ketamine LC/MS 35128 pos allopurinol riboside GC/MS 38321 vecuronium LC/MS 42591 pos oxypurinol GC/MS 41725 allopurinol GC/MS 43534 Food 5-ketogluconate GC/MS 15687 component/ N-glycolylneuraminate GC/MS 37123 Plant stachydrine LC/MS 34384 pos homostachydrine* LC/MS 33009 pos Sugar, sugar erythritol GC/MS 20699 substitute, starch

TABLE 9 Biomarkers in bile, grouped by divergent pathways within known molecular groups/pathways Super Sub Biochemical Plat- Comp Pathway Pathway Name form ID Amino Glycine, glycine GC/MS 11777 acid serine and dimethylglycine GC/MS 5086 threonine N-acetylglycine GC/MS 27710 metabolism beta-hydroxypyruvate GC/MS 15686 serine GC/MS 1648 threonine LC/MS 1284 pos N-acetylthreonine LC/MS 33939 neg betaine LC/MS 3141 pos Alanine asparagine GC/MS 34283 and beta-alanine GC/MS 55 aspartate 3-ureidopropionate LC/MS 3155 metabolism pos N-acetyl-beta-alanine LC/MS 37432 pos alanine GC/MS 1126 N-acetylalanine LC/MS 1585 neg Glutamate glutamate LC/MS 57 metabolism pos glutamine LC/MS 53 pos Histidine histidine LC/MS 59 metabolism neg trans-urocanate LC/MS 607 pos 1-methylimidazole- LC/MS 32350 acetate pos Lysine lysine LC/MS 1301 metabolism pos 2-aminoadipate LC/MS 6146 pos pipecolate GC/MS 1444 N6-acetyllysine LC/MS 36752 pos Phenyl- phenyllactate (PLA) LC/MS 22130 alanine & neg tyrosine phenylalanine LC/MS 64 metabolism pos phenylacetate GC/MS 15958 p-cresol sulfate LC/MS 36103 neg m-cresol sulfate LC/MS 36846 neg tyrosine LC/MS 1299 pos 3-(4-hydroxy- LC/MS 32197 phenyl)lactate neg vanillylmandelate LC/MS 1567 (VMA) neg 4-hydroxyphenyl- LC/MS 1669 pyruvate neg 4-hydroxyphenyl- GC/MS 541 acetate 3,4-dihydroxy- LC/MS 18296 phenylacetate neg phenylacetylglycine LC/MS 33945 neg phenol sulfate LC/MS 32553 neg 4-hydroxyphenyl- LC/MS 43525 acetyl glycine neg Tryptophan kynurenate LC/MS 1417 metabolism neg kynurenine LC/MS 15140 pos tryptophan LC/MS 54 pos indolelactate GC/MS 18349 N-acetyl- LC/MS 33959 tryptophan neg C-glycosyl- LC/MS 32675 tryptophan* pos 3-indoxyl LC/MS 27672 sulfate neg Valine, 3-methyl-2- LC/MS 21047 leucine oxobutyrate neg and 3-methyl-2- LC/MS 15676 isoleucine oxovalerate neg metabolism beta-hydroxy- GC/MS 12129 isovalerate alpha-hydroxy- GC/MS 22132 isocaproate isoleucine LC/MS 1125 pos leucine LC/MS 60 pos N-acetylleucine LC/MS 1587 pos N-acetyl- LC/MS 33967 isoleucine pos tigloylglycine LC/MS 1598 pos valine LC/MS 1649 pos 3-hydroxyisobutyrate GC/MS 1549 4-methyl-2- LC/MS 22116 oxopentanoate neg 3-hydroxy-2- GC/MS 32397 ethylpropionate alpha-hydroxy- GC/MS 33937 isovalerate isovalerylglycine LC/MS 35107 neg isobutyrylcarnitine LC/MS 33441 pos 2-methylbutyryl- LC/MS 35431 carnitine (C5) pos 2-methylbutyryl- LC/MS 31928 glycine pos 3-methylcrotonyl- LC/MS 31940 glycine pos isovalerylcarnitine LC/MS 34407 pos tiglyl carnitine LC/MS 35428 pos 3-methylglutaryl- LC/MS 37060 carnitine (C6) pos Cysteine, cysteine GC/MS 31453 methionine, S-methylcysteine LC/MS 39592 SAM, pos taurine cystine GC/MS 31454 metabolism S-adenosylhomo- LC/MS 15948 cysteine (SAH) neg methionine LC/MS 1302 pos N-acetylmethionine LC/MS 1589 neg 2-hydroxybutyrate GC/MS 21044 (AHB) homocysteine GC/MS 40266 Urea dimethylarginine LC/MS 36808 cycle; (SDMA + ADMA) pos arginine-, arginine LC/MS 1638 proline-, pos metabolism ornithine GC/MS 1493 urea GC/MS 1670 proline LC/MS 1898 pos citrulline LC/MS 2132 pos trans-4- LC/MS 32306 hydroxyproline pos homocitrulline LC/MS 22138 pos N-delta- LC/MS 43249 acetylornithine* pos N2,N5- LC/MS 43591 diacetylornithine neg Creatine creatine LC/MS 27718 metabolism pos creatinine LC/MS 513 pos Butanoate 2-aminobutyrate LC/MS 32348 metabolism pos Polyamine 5-methylthio- LC/MS 1419 metabolism adenosine (MTA) pos acisoga LC/MS 43258 pos Glutathione S-methyl- LC/MS 33944 glutathione pos metabolism 5-oxoproline LC/MS 1494 neg glutathione, LC/MS 27727 oxidized (GSSG) pos cysteine-glutathione LC/MS 35159 disulfide pos ophthalmate LC/MS 34592 pos Peptide Dipeptide glycylproline LC/MS 22171 pos leucylleucine LC/MS 36756 pos pro-hydroxy-pro LC/MS 35127 pos cysteinylglycine GC/MS 35637 valylalanine LC/MS 41518 pos aspartylleucine LC/MS 40068 pos isoleucylalanine LC/MS 40046 pos leucylalanine LC/MS 40010 pos leucylglutamate LC/MS 40021 pos leucylphenylalanine LC/MS 40026 neg leucylserine LC/MS 40048 neg serylleucine LC/MS 40066 pos threonylleucine LC/MS 40051 pos tyrosylleucine LC/MS 40031 pos Dipeptide carnosine LC/MS 1768 derivative neg anserine LC/MS 15747 neg cys-gly, oxidized LC/MS 18368 neg N-acetylcarnosine LC/MS 43488 pos gamma- gamma-glutamylvaline LC/MS 32393 glutamyl pos gamma-glutamyl- LC/MS 37092 2-aminobutyrate pos gamma- LC/MS 18369 glutamylleucine pos gamma- LC/MS 34456 glutamylisoleucine* pos gamma- LC/MS 33949 glutamylglycine pos gamma- LC/MS 37539 glutamylmethionine pos gamma- LC/MS 33422 glutamylphenylalanine pos gamma- LC/MS 2734 glutamyltyrosine pos gamma- LC/MS 33364 glutamylthreonine* pos gamma- LC/MS 33947 glutamyltryptophan pos gamma- LC/MS 37063 glutamylalanine pos Carbo- Aminosugars erythronate* GC/MS 33477 hydrate metabolism fucose GC/MS 15821 glucuronate GC/MS 15443 Fructose, fructose GC/MS 577 mannose, galactose GC/MS 12055 galactose, mannitol GC/MS 15335 starch, and mannose GC/MS 584 sucrose sorbitol GC/MS 15053 metabolism sucrose LC/MS 1519 neg raffinose LC/MS 586 neg Oligo- lactobionate GC/MS 20685 saccharide Glycolysis, glycerate GC/MS 1572 gluconeo- glucose 1-phosphate GC/MS 33755 genesis, glucose GC/MS 20488 pyruvate 1,6-anhydroglucose GC/MS 21049 metabolism pyruvate GC/MS 599 lactate GC/MS 527 Isobar: LC/MS 33001 glucuronate, neg galacturonate, 5-keto-gluconate Glyoxylate oxalate LC/MS 20694 and (ethanedioate) neg dicarboxylate metabolism Nucleotide arabitol GC/MS 38075 sugars, ribitol GC/MS 15772 pentose threitol GC/MS 35854 metabolism gluconate GC/MS 587 ribose GC/MS 12080 ribonate GC/MS 38818 ribulose GC/MS 35855 xylitol GC/MS 41319 arabinose GC/MS 575 xylose GC/MS 15836 xylonate GC/MS 35638 xylulose GC/MS 18344 Energy Krebs citrate GC/MS 1564 cycle cis-aconitate LC/MS 12025 neg alpha-ketoglutarate GC/MS 33453 succinate LC/MS 1437 neg fumarate GC/MS 1643 malate GC/MS 1303 Oxidative acetylphosphate GC/MS 15488 phos- phosphate GC/MS 11438 phorylation Lipid Essential linoleate (18:2n6) LC/MS 1105 fatty acid neg linolenate [alpha LC/MS 34035 or gamma; neg (18:3n3 or 6)] dihomo-linolenate LC/MS 35718 (20:3n3 or n6) neg eicosapentaenoate LC/MS 18467 (EPA; 20:5n3) neg docosapentaenoate LC/MS 32504 (n3 DPA; 22:5n3) neg docosapentaenoate LC/MS 37478 (n6 DPA; 22:5n6) neg docosahexaenoate LC/MS 19323 (DHA; 22:6n3) neg Medium caproate (6:0) LC/MS 32489 chain neg fatty heptanoate (7:0) LC/MS 1644 acid neg caprylate (8:0) LC/MS 32492 neg pelargonate (9:0) GC/MS 12035 laurate (12:0) GC/MS 1645 2-aminoheptanoic LC/MS 43761 acid pos Long myristate (14:0) LC/MS 1365 chain neg fatty pentadecanoate LC/MS 1361 acid (15:0) neg palmitate (16:0) LC/MS 1336 neg palmitoleate LC/MS 33447 (16:1n7) neg margarate (17:0) LC/MS 1121 neg 10-heptadecenoate LC/MS 33971 (17:1n7) neg stearate (18:0) LC/MS 1358 neg oleate (18:1n9) GC/MS 1359 cis-vaccenate GC/MS 33970 (18:1n7) nonadecanoate LC/MS 1356 (19:0) neg 10-nonadecenoate LC/MS 33972 (19:1n9) neg arachidate (20:0) LC/MS 44679 neg eicosenoate LC/MS 33587 (20:1n9 or 11) neg dihomo-linoleate LC/MS 17805 (20:2n6) neg mead acid (20:3n9) LC/MS 35174 neg arachidonate LC/MS 1110 (20:4n6) neg docosadienoate LC/MS 32415 (22:2n6) neg adrenate (22:4n6) LC/MS 32980 neg Fatty 9,10-epoxystearate LC/MS 39627 acid, neg oxidized Fatty myristate, methyl ester GC/MS 12289 acid, pentadecanoate, GC/MS 12288 methyl methyl ester ester palmitate, methyl ester GC/MS 12091 margarate, methyl ester GC/MS 11984 stearate, methyl ester GC/MS 6097 oleate, methyl ester GC/MS 36796 linoleate, methyl ester GC/MS 36801 Fatty 3-hydroxypropanoate GC/MS 42103 acid, 2-hydroxystearate LC/MS 17945 mono- neg hydroxy 2-hydroxypalmitate LC/MS 35675 neg Fatty 2-hydroxyglutarate GC/MS 37253 acid, sebacate LC/MS 32398 dicarb- (decanedioate) neg oxylate azelate LC/MS 18362 (nonanedioate) neg Fatty acid, stearamide GC/MS 37487 amide Fatty acid, suberylglycine LC/MS 35419 beta- neg oxidation Fatty acid, 13-methylmyristic LC/MS 38293 branched acid neg 15-methylpalmitate LC/MS 38768 (isobar with 2- neg methylpalmitate) 17-methylstearate LC/MS 38296 neg Fatty acid propionylcarnitine LC/MS 32452 metabolism pos (also BCAA propionylglycine LC/MS 31932 metabolism) neg butyrylcarnitine LC/MS 32412 pos Fatty acid isovalerate LC/MS 34732 metabolism neg hexanoylglycine LC/MS 35436 neg Carnitine deoxycarnitine LC/MS 36747 metabolism pos carnitine LC/MS 15500 pos 3-dehydrocarnitine* LC/MS 32654 pos acetylcarnitine LC/MS 32198 pos hexanoylcarnitine LC/MS 32328 pos octanoylcarnitine LC/MS 33936 pos laurylcarnitine LC/MS 34534 pos palmitoylcarnitine LC/MS 22189 pos stearoylcarnitine LC/MS 34409 pos oleoylcarnitine LC/MS 35160 pos Bile acid glycocholate LC/MS 18476 metabolism pos glycohyocholate LC/MS 42574 pos taurohyocholate LC/MS 42603 neg taurochenode- LC/MS 18494 oxycholate neg taurodeoxycholate LC/MS 12261 neg glycodeoxycholate LC/MS 18477 neg glycochenode- LC/MS 32346 oxycholate neg glycolithocholate LC/MS 31912 neg glycolithocholate LC/MS 32620 sulfate* neg taurolithocholate LC/MS 31889 neg glycocholenate LC/MS 32599 sulfate* neg taurocholenate sulfate* LC/MS 32807 neg glycohyodeoxycholic LC/MS 43501 acid pos Glycerolipid ethanolamine GC/MS 1497 metabolism glycerol GC/MS 15122 choline LC/MS 15506 pos glycerol 3-phosphate GC/MS 15365 (G3P) glycerophosphoryl- LC/MS 15990 choline (GPC) pos Inositol myo-inositol GC/MS 19934 metabolism chiro-inositol GC/MS 37112 pinitol GC/MS 37086 inositol GC/MS 1481 1-phosphate (I1P) Ketone 3-hydroxybutyrate GC/MS 542 bodies (BHBA) 1,2-propanediol GC/MS 38002 Lysolipid 1-palmitoylglycero- LC/MS 35631 phosphoethanolamine neg 2-palmitoylglycero- LC/MS 35688 phosphoethanolamine* neg 1-stearoylglycero- LC/MS 34416 phosphoethanolamine neg 1-oleoylglycero- LC/MS 35628 phosphoethanolamine neg 1-linoleoylglycero- LC/MS 32635 phosphoethanolamine* neg 2-linoleoylglycero- LC/MS 36593 phosphoethanolamine* neg 1-arachidonoylglycero- LC/MS 35186 phosphoethanolamine* neg 2-arachidonoylglycero- LC/MS 32815 phosphoethanolamine* neg 1-stearoylglycero- LC/MS 34437 phosphoglycerol neg 2-myristoylglycero- LC/MS 35626 phosphocholine* pos 1-palmitoylglycero- LC/MS 33955 phosphocholine (16:0) neg 2-palmitoylglycero- LC/MS 35253 phosphocholine* neg 1-palmitoleoylglycero- LC/MS 33230 phosphocholine (16:1)* pos 1-margaroylglycero- LC/MS 33957 phosphocholine (17:0) neg 1-stearoylglycero- LC/MS 33961 phosphocholine (18:0) pos 2-stearoylglycero- LC/MS 35255 phosphocholine* pos 1-oleoylglycerophos- LC/MS 33960 phocholine (18:1) neg 2-oleoylglycero- LC/MS 35254 phosphocholine* neg 1-linoleoylglycero- LC/MS 34419 phosphocholine (18:2n6) neg 2-linoleoylglycero- LC/MS 38087 phosphocholine* neg 1-dihomo-linoleoylglycero- LC/MS 33871 phosphocholine (20:2n6)* pos 1-eicosatrienoylglycero- LC/MS 33821 phosphocholine (20:3)* pos 1-arachidonoylglycero- LC/MS 33228 phosphocholine (20:4n6)* pos 2-arachidonoylglycero- LC/MS 35256 phosphocholine* pos 1-docosapentaenoyl- LC/MS 37231 glycero- pos phosphocholine (22:5n3)* 1-docosahexaenoylglycero- LC/MS 33822 phosphocholine (22:6n3)* pos 2-docosahexaenoyl- LC/MS 35883 glycero- neg phosphocholine* 1-palmitoylplasmenyl- LC/MS 39270 ethanolamine* neg 1-stearoylplasmenyl- LC/MS 39271 ethanolamine* neg 1-docosahexaenoyl- LC/MS 44633 glycero- neg phosphoethanolamine* 1-linolenoylglycero- LC/MS 44562 phosphocholine (18:3n3)* pos 1-eicosapentaenoyl- LC/MS 44563 glycero- pos phosphocholine (20:5n3)* Mono- 1-palmitoylglycerol GC/MS 21127 acyl- (1-monopalmitin) glycerol 1-oleoylglycerol LC/MS 21184 (1-monoolein) pos 1-linoleoylglycerol LC/MS 27447 (1-monolinolein) neg Sphingo- sphingosine LC/MS 17747 lipid pos palmitoyl sphingomyelin GC/MS 37506 stearoyl sphingomyelin GC/MS 19503 Sterol/ lathosterol GC/MS 39864 Steroid cholesterol GC/MS 63 campesterol GC/MS 39511 4-androsten-3beta, LC/MS 37202 17beta-diol disultate 1* neg 4-androsten-3beta, LC/MS 37203 17beta-diol disulfate 2* neg 5alpha-androstan-3beta, LC/MS 37190 17beta-diol disulfate neg 5alpha-pregnan-3beta, LC/MS 37198 20alpha-diol disulfate neg pregnen-diol disulfate* LC/MS 32562 neg 21-hydroxy- LC/MS 37173 pregnenolone disulfate neg Nucleo- Purine xanthine GC/MS 3147 tide metabolism, xanthosine LC/MS 15136 (hypo) neg xanthine/ hypoxanthine LC/MS 3127 inosine pos containing inosine LC/MS 1123 neg 2′-deoxyinosine LC/MS 15076 neg Purine adenine LC/MS 554 metabolism, pos adenine adenosine LC/MS 555 containing pos N1-methyladenosine LC/MS 15650 pos adenosine-2′,3′-cyclic LC/MS 37467 monophosphate pos Purine guanine GC/MS 418 metabolism, 7-methylguanine LC/MS 35114 guanine pos containing guanosine LC/MS 1573 neg 2′-deoxy- LC/MS 1411 guanosine neg N1-methylguanosine LC/MS 31609 pos N2, N2-dimethyl- LC/MS 35137 guanosine pos N6-carbamoylthreonyl- LC/MS 35157 adenosine pos Purine urate GC/MS 1604 metabolism, allantoin GC/MS 1107 urate metabolism Pyrimidine cytidine LC/MS 514 metabolism, neg cytidine 2′-deoxycytidine LC/MS 15949 containing pos Pyrimidine orotate GC/MS 1505 metabolism, orotate containing Pyrimidine thymidine LC/MS 2183 metabolism, pos thymine containing Pyrimidine uridine LC/MS 606 metabolism, neg uracil pseudouridine LC/MS 33442 containing pos Purine and methylphosphate GC/MS 37070 pyrimidine metabolism Cofactors Ascorbate gulono-1,4-lactone GC/MS 33454 and and threonate GC/MS 27738 vitamins aldarate glucurono-6,3-lactone GC/MS 20680 metabolism arabonate GC/MS 37516 Pterins isoxanthopterin LC/MS 27732 pos Hemoglobin heme LC/MS 41754 and pos porphyrin L-urobilin LC/MS 40173 metabolism neg Coproporphyrin I LC/MS 39318 neg coproporphyrin III LC/MS 39317 neg bilirubin (Z,Z) LC/MS 27716 neg bilirubin (E,E)* LC/MS 32586 neg biliverdin LC/MS 2137 neg protoporphyrin LC/MS 39321 IX neg Nicotinate nicotinamide LC/MS 594 and pos nicotinamide quinolinate GC/MS 1899 metabolism N1-Methyl-2-pyridone- LC/MS 40469 5-carboxamide neg Pantothenate pantothenate LC/MS 1508 and neg CoA metabolism Pyridoxal pyridoxate LC/MS 31555 metabolism neg Riboflavin riboflavin LC/MS 1827 metabolism (Vitamin B2) pos Tocopherol alpha-tocopherol GC/MS 1561 metabolism Xeno- Benzoate hippurate LC/MS 15753 biotics metabolism neg 3-hydroxyhippurate LC/MS 39600 neg 4-hydroxyhippurate LC/MS 35527 neg 3-hydroxymandelate GC/MS 22112 4-hydroxymandelate GC/MS 1568 benzoate GC/MS 15778 p-hydroxybenzaldehyde GC/MS 17665 Chemical glycolate (hydroxyacetate) GC/MS 15737 2-hydroxyisobutyrate GC/MS 22030 glycerol 2-phosphate GC/MS 27728 3-hydroxypyridine GC/MS 21169 HEPES LC/MS 21248 neg 2-ethylhexanoate LC/MS 35490 (isobar with 2- neg propylpentanoate) 2-mercaptoethanol* GC/MS 37225 2-piperidinone LC/MS 43400 pos dimethyl sulfone LC/MS 43424 pos Drug ketamine LC/MS 35128 pos methylprednisolone LC/MS 42977 pos pantoprazole LC/MS 38609 neg vecuronium LC/MS 42591 pos oxypurinol GC/MS 41725 Food 5-ketogluconate GC/MS 15687 component/ quinate GC/MS 18335 Plant benzyl alcohol GC/MS 22294 ergothioneine LC/MS 37459 pos N-(2-furoyl)glycine LC/MS 31536 pos stachydrine LC/MS 34384 pos homostachydrine* LC/MS 33009 pos cinnamoylglycine LC/MS 38637 neg 1,1-kestotetraose LC/MS 39796 neg equol glucuronide LC/MS 41948 neg Sugar, erythritol GC/MS 20699 sugar substitute, starch Bacterial Isobar: tartronate, GC/MS 42356 dihydroxyfumarate Phthalate bis(2-ethylhexyl)phthalate GC/MS 21069

Example 5 Biomarkers of Liver Function

This example describes the identification of biomarkers of liver function.

The glucose-amino acid cycle and branched-chain amino acid mobilization were markedly elevated in livers undergoing machine perfusion as described in Example 1. Glucose was elevated in MP relative to CSP liver perfusates throughout the study and may have been converted to lactate via the glycolysis pathway. In spite a small amount of glucose being initially present at the perfusate in the machine perfusion group, a constant rate of gluconeogenesis can be detected when additional metabolites are analyzed (FIG. 20A). Lactate is a predominant source of carbon atoms for glucose synthesis by gluconeogenesis. The livers had an intact aerobic metabolism and were able to convert lactate into pyruvate (FIGS. 20B and 20C). The same metabolic pathway can be illustrated by the progressive production of fructose-6-phosphate and glycose-6-phosphate in the livers under machine perfusion (FIGS. 20D and 20E).

Branched-chain amino acid (BCAA) oxidation showed a strong differential increase in machine perfusion perfusates at the 6 and 9 hour time points as demonstrated by the BCAAs valine, isoleucine, and leucine (FIG. 17A-17C) and their respective deamination products 3-methyl-2-oxobutyrate, 3-methyl-2-oxovalerate, and 4-methyl-2-oxopentanoate. Several primary metabolites and side-products of the BCAA pathways were elevated in the machine perfusion group. Deamination by branched-chain aminotransferase (BCAT) is the first (and fully reversible) step in the oxidation of BCAAs and is followed by the irreversible mitochondrial reaction catalyzed by branched-chain ketoacid dehydrogenase. The tricarboxylic acid (TCA) cycle component alpha-ketoglutarate is a co-substrate for BCAT and leads to the co-formation of glutamate. Alpha-ketoglutarate and glutamate were both elevated in the machine perfusion group relative to the cold storage group at 6 and 9 hour as was glutamine, which can be derived from glutamate. It is possible that alpha-ketoglutarate, glutamate, and glutamine were elevated in response to demand for alpha-ketoglutarate that promoted its production by the TCA cycle and its subsequent conversion to glutamate via the action of BCAT (FIGS. 21A and 21B).

Perfusate profiling revealed differences in stress responses over time between the two preservation conditions. Biochemicals that provide insight into oxidative, inflammatory, and energy stress were among those showing a strong separation between perfusate profiles from the two preservation conditions. For instance, although there were only 2 samples in the perfusate CSP group at the baseline (0 hour) time point, ascorbate was detected in both whereas it was not detected in any of the MP baseline samples. It was detected in all samples from the 6 and 9 hour time points in the CSP samples but was not detected in any of the MP samples at these time points (FIG. 22). Pigs, unlike humans, are capable of synthesizing ascorbate but the expression of the key synthetic enzyme, L-gulono-gamma-lactone oxidase, varies with stress, so ascorbate's presence in the cold static preservation group samples but absence in the machine perfusion samples could be an indication of different levels of perceived oxidant stress by livers subjected to the different preservation conditions.

Evidence of lipoxygenase activity was observed and differed by preservation method. 15-HETE, the product of 15-lipoxygenase, was specifically elevated in machine perfusion perfusates whereas 12-HETE, the product of 12-lipoxygenase, was stably elevated in the cold storage preservation perfusate across all time points but was low in all MP perfusate samples (FIGS. 23A and 23B). 15-lipoxygenase is believed to play a role in the selective breakdown and recycling of peroxisomes whereas 12-HETE (and 15-HETE to a lesser extent) has a more traditional role in promoting inflammation. Altogether this suggests that inflammation was greater in the CSP group than MP samples.

Finally, bile production was increased within both 24 hours of liver allograft perfusion and over the 5-day post-operative period (FIG. 24). This indicates overall organ function. In addition, biomarkers from bile could be used as indicators of organ function or dysfunction.

Example 6 Principal Component Analysis of Liver Perfusate

This example describes principal component analysis (PCA) of perfusate from MP or CSP livers.

PCA is a tool for defining primary characteristics of a highly-dimensional dataset. The analysis achieves dimension reduction by extracting a few (but not all) principal components that describe most of the variation in the original multivariate dataset with the least loss of information. Based on linear transformation and decomposition of a number of correlated variables of a multi-dimensional dataset to a number of uncorrelated components, principal components are identified. The principal components are estimated as the projections of the data set on the eigenvectors of the covariance or correlation matrix of the data set. See, e.g., Janes et al., Nat. Rev. Mol. Cell. Biol. 7:820, 2006; Mi et al., PLoS ONE 6:19424, 2011.

PCA was carried out on the metabolomics profile of liver perfusates from MP or CSP livers at 3, 6, and 9 hour time points. In the MP livers, variables representing carbohydrate metabolism (ribulose, ribose, glycolate) and antioxidant defenses (oxidized homo-glutathione (GSSG)) were principal drivers of metabolic changes (FIG. 25). In the CSP livers, PCA showed ethanolamine to be the principal driver of metabolic changes, suggesting a role for fatty acid metabolism (FIG. 26).

Example 7 Dynamic Bayesian Network Analysis of Liver Perfusate

The example describes dynamic Bayesian network (DBN) analysis of perfusate from MP or CSP livers.

DBN analysis infers graphs for each component individually from each liver. If an arrow exists in >50% of the individual networks, it is included in the final consensus network. The thickness of the arrows indicate the percentage of individual networks in which it is present (FIG. 27).

DBN was used to determine the role of different cytokines while interacting in response to an initial inflammatory event (e.g., ischemia-reperfusion acquired during liver preservation). The analysis suggests two different pathways for cytokine regulation in livers being perfused by CSP or MP (FIG. 28).

In view of the many possible embodiments to which the principles of the disclosure may be applied, it should be recognized that the illustrated embodiments are only examples and should not be taken as limiting the scope of the invention. Rather, the scope of the invention is defined by the following claims. We therefore claim as our invention all that comes within the scope and spirit of these claims. 

1. A method for identifying organ dysfunction, comprising determining an amount of one or more biomarkers from a biological sample obtained from an organ, wherein the one or more biomarkers comprise one or more small molecules, nucleic acids, chemokines and/or cytokines, or any combination thereof; determining whether the amount of the one or more biomarkers differs from an amount of the one or more biomarkers in a control sample or reference value; and identifying the organ dysfunction if the amount of the one or more biomarkers differs from the control sample or reference value.
 2. The method of claim 1, wherein the one or more biomarkers comprise one or more small molecules.
 3. The method of claim 2, wherein the one or more biomarkers comprise ribulose, ribose, glycolate, oxidized homo-glutathione (GSSG), and ethanolamine.
 4. The method of claim 3, wherein the amount of ribose, ribulose, and glycolate is decreased compared to the control sample or reference value and the amount of GSSG and ethanolamine is increased compared to the control sample or reference value and is an indicator of organ dysfunction. 5-7. (canceled)
 8. The method of claim 1, wherein the one or more biomarkers comprise one or more nucleic acids.
 9. The method of claim 8, wherein the one or more nucleic acids comprise one or more nucleic acids associated with cell proliferation, metabolic function, free-radical defense, and/or cell differentiation.
 10. The method of claim 9, wherein expression of the one or more nucleic acids is decreased compared to the control sample or reference value and the one or more nucleic acids encodes Jun, NFκB, apolipoprotein A-II, superoxide dismutase 1, acyl coenzyme A synthetase, thrombospondin 1, prothymosin, alpha, cytochrome c oxidase subunit II, and/or alpha-2-macroglobulin, wherein the decrease in expression of the one or more nucleic acids is an indicator of organ dysfunction.
 11. (canceled)
 12. The method of claim 1, wherein the one or more biomarkers comprise one or more cytokines and/or chemokines.
 13. The method of claim 12, wherein the amount of the one or more cytokines and/or chemokines is increased compared to the control sample or reference value and the one or more cytokines and/or chemokines comprise interferon-α, interferon-γ, interleukin-4, interleukin-1β, interleukin-12/interleukine-23 (p40), and/or tumor necrosis factor-α, wherein the increase in the one or more cytokines and/or chemokines is an indicator of organ dysfunction.
 14. (canceled)
 15. The method of claim 1, wherein the sample from the organ comprises a tissue sample, a perfusate from the organ, or a fluid produced by the organ.
 16. The method of claim 1, wherein the organ is a liver, a kidney, a lung, a heart, a pancreas, a small intestine, a limb, an extremity, or a portion of any one thereof.
 17. The method of claim 1, wherein the organ is being evaluated for its viability following transplantation into a subject.
 18. (canceled)
 19. The method of claim 1, wherein the organ is undergoing machine perfusion.
 20. The method of claim 19, wherein the organ is undergoing machine perfusion with a perfusion solution comprising a hemoglobin-based oxygen carrier.
 21. The method of claim 20, wherein the perfusion solution comprises about 3-4 g/dL cross-linked hemoglobin, 25-30 mM NaCl, 1-2 mM KCl, 17-19 mM KH₂PO₄, 55-65 mM sodium gluconate, 6-8 mM sodium lactate, 3-4 mM magnesium gluconate, 0.6-0.8 mM CaCl₂ dihydrate, 15-16 mM NaOH, 3-4 mM adenine, 6-8 mM dextrose, 2-3 mM glutathione, 6-8 mM HEPES, 3-4 mM ribose, 20-25 mM mannitol, 35-40 g/L hydroxyethyl starch, and 40-60 mg/dL N-acetyl-L-cysteine. 22-24. (canceled)
 25. The method of claim 1, wherein the control sample or reference value comprise one or more organs that are known to have organ dysfunction.
 26. The method of claim 1, wherein the control sample or reference value comprise one or more organs that are known not to have organ dysfunction
 27. The method of claim 1, further comprising: utilizing the amount of the one or more biomarkers as a predictor of organ function to select the organ; and transplanting the selected organ into a transplant recipient. 